Columbia  Winihtx^ii^ 
in  t^t  €itv  of  ileto  gorfe 

College  of  l^ftpiiciani  anb  ^urseonsi 


Bt.  dialler  P.  famess 


FLATULENCE 


AND 


SHOCK 


BY 


F.  G.  CROOKSHANK,  M.D.  Lond.,  M.R.C.P. 

PHYSICIAN  (OUT-PATIENTS),  HAMPSTEAD  GENERAL  AND  N.-W.  LOND.  HOSPITAL  ;  ASST.  PHYSICIAN, 
THE  BELGRAVE  HOSPITAL  FOR  CHILDREN,  S.W. 


PAUL  B.  HOEBER 

6g,    EAST    59TH    STREET 

NEW   YORK 

1913 

Printed  in  England] 


PREFACE 

I  HAVE  been  asked  that  these  two  papers  should  be  printed, 
rather,  I  suspect,  for  the  sake  of  the  bibhography — such  as  it 
is — than  for  any  other  reason.  Still,  I  confess  to  surprise 
at  the  interest  that  has  been  evoked,  and  have  been  almost 
startled  at  the  really  large  number  of  isolated  facts,  bearing 
on  the  subjects  discussed,  that  have  been  brought  to  one's 
notice.  Thus  Dr.  Spilsbury,  who  tells  me  that  he  has  not 
always  found  the  coeliac  axis  degenerate  when  there  has  been 
pretty  widespread  arterio-sclerosis,  says  that  nevertheless  in 
such  cases  there  is  often  marked  hypertrophy  of  the  muscular 
coat  of  the  vessel.  The  relevancy  of  this  point  to  the  sugges- 
tion of  spasm  and  excessive  adrenalism  is  obvious.  In  respect 
of  the  second  paper,  during  discussion  both  Sir  John  Tweedy 
and  Dr.  F.  J.  Smith  narrated  some  cases  that  were  very 
a  propos,  and  I  have  heard  since  of  many  others.  Mr.  Roland 
Burrows,  himself  a  lawyer,  raised  the  interesting  point 
whether  indeed  the  neurasthenia  of  twentieth-century  males 
may  not  be  a  consequence  of  "  repression,"  and  whether  the 
emotional  displays  of  our  eighteenth-century  heroes  and 
statesmen — ^who  lived  in  shocking  times — may  not  have  been 
physiologically  justified.  Such  suggestions  give  an  even  wider 
significance  to  the  Freudian  doctrines. 

The  comments  of  the  anaesthetists  are  very  interesting. 

The  declaration  by  not  a  few  that  "  surgical  shock  "  is 
very  often  a  matter  of  overdeep  anaesthesia  seems  based  on 
sound  clinical  observation,  and  should  be  correlated  with 
Verwom's  masterly  elucidation  of  the  phenomena  of  narcosis. 

Again,  it  is  impossible  to  ignore  the  theoretical  importance 
of  the  marked  success  that  Dr.  H.  M.  Page  and  others  have 
enjoyed  with  the  prolonged  administration  of  nitrous  oxide 


vi  PREFACE 

gas  and  oxygen.  It  has  been  suggested  that  this  method  of 
producing  anaesthesia  not  only  avoids  the  paralyzing  effect 
on  the  oxygen-carriers,  postulated  by  Verwom,  but  has 
something  to  do  with  checking  the  loss  of  carbonic  acid  gas, 
which,  whether  by  the  lungs  or  from  the  open  abdomen,  is 
the  essential  factor  in  the  production  of  acapnia. 

Certainly  Embley,  whose  paper  in  the  Australian  Medical 
Journal,  for  August  17,  1912,  deserves  careful  study, 
recognizes  respiratory  depression  under  anaesthesia  as  con- 
nected with  loss  of  carbonic  acid  gas.  He  finds  shock  to  be 
less  when  nitrous  oxide  and  oxygen  are  given  with  ether  by 
the  closed  method  than  otherwise ;  and  commends  the 
therapeutic  administration  of  carbonic  acid  gas  itself  when 
the  respiration  is  depressed  under  chloroform  or  open  ether. 

In  the  Lancet  for  October  26, 1912,  there  is  given,  on  p.  1167, 
an  account  of  a  case  of  "  intestinal  obstruction,  the  result  of 
abdominal  injury,"  in  which,  at  the  necropsy,  no  relevant 
lesion  was  found.  There  are  also  valuable  references  to 
Nothnagel's  Encyclopaedia,  and  to  a  case  reported  by  Drs. 
Kempe  and  Browne,  wherein  the  early  meteorism  and  con- 
stipation passed  off,  to  return  later  and  necessitate  laparotomy. 
In  the  same  issue  of  the  Lancet  there  is  a  letter  from  Dr. 
Donald  Hood,  which  is  deeply  interesting.  Dr.  Hood  insists 
that  we  are  apt  to  overlook  the  fact  that,  in  many  cases,  the 
maximum  effect  of  arterial  disease  is  purely  local. 

F.  G.  C. 

53,  Welbeck  Street,  W. 
October,  19 12. 


FLATULENCE* 


There  is  a  line  in  Horace  which  has  been  translated,  though 
with  doubtful  accuracy,  "  It  is  difficult  to  speak  with  propriety 
of  common  things."  Jack  Wilkes,  as  all  who  care  for  Boswell 
know,  illustrated  this  notion  by  referring  to  the  embarrass- 
ment of  a  poet  laureate  who  should  describe  her  most  Gracious 
Majesty  Queen  Caroline  as  engaged  in  washing  teacups. 
Alike,  too,  was  the  difficulty  which  tradition  in  Mortlake  tells 
us  was  felt  by  a  worthy  local  physician,  called  to  attend  that 
august  lady,  when  in  residence  at  Kew  and  suffering  from 
what  charwomen  call  the  "  windy  spasms."  How  to  devise 
a  signature  to  his  prescription,  at  once  respectful  to  his 
sovereign  and  yet  likely  to  be  understood  by  the  local  apothe- 
cary, gave  him  pause.  It  is  said  that  in  the  upshot  the  appro- 
priate carminative  draught  was  ordered  to  be  taken  "  quum 
Regina  habet  ventum."  This  may  not  be  true  ;  but  I  have 
some  diffidence  in  commending  the  vulgar  subject  of  flatulence 
to  you.  Yet  it  is  one  of  great  practical  importance  and  no 
little  theoretical  interest.  Occasion  is  not  always  adequately 
met  by  the  perfunctory  exhibition  of  Mist.  Carminativa ;  and, 
though  in  Casualty  one  may  be  able  successfully  to  fob  off  a 
vexatious  patient,  yet,  in  private  practice,  one  who  is  suffering 
torments  has  little  satisfaction  if  his  doctor  deems  him  a 
neurotic  nuisance,  and,  like  Dogberry,  thanks  God  when  rid 
of  a  pestOent  knave. 

Should  we  ask  point-blank  whence  comes  the  gas  eructated 
in  flatulence;  or  distending  the  abdomen  in  cases  of  meteorism, 
the  answer  usually  is,  "  From  fermentation."  If  we  press,  it 
may  be  admitted  that,  certainly,  there  are  also  some  "  neu- 
rotic "  cases.  But  to  label  the  condition  of  one  in  distress 
either  "  neurotic  "  or  "  functional  "  does  not  carry  us  far  ; 

*  A  paper  read  before  the  Medical  Society  of  St.  Mary's  Hospital, 
London,  October  23,  1912. 

7 


8  FLATULENCE 

and  so  others  take  refuge  in  saying  that  the  gas  is  really 
swallowed  air,  though  surgeons  who  have  experience  of  ileus 
Imow  full  well  that  this  will  not  do.  They,  as  a  rule,  frankly 
admit  that  there  is  at  work  some  influence  that  has  not  yet 
been  "  precised." 

Physicians  are  somewhat  less  candid. 

In  cases  of  chronic  gastric  dilatation  without  organic  ob- 
struction at  the  pylorus,  there  is,  of  course,  a  definite  forma- 
tion of  lactic  and  butyric  acids,  with  evolution  of  carbonic 
acid  and  hydrogen.  It  is  accepted  that  these  processes  are 
the  result  of  microbic  fermentation,  and  also  that,  when  yeast 
is  present,  the  alcoholic  and  acetic  fermentations  may  proceed 
with  like  evolution  of  gas.  It  is  also  seemingly  true  that, 
when  certain  articles  of  food  have  been  ingested,  sulphuretted 
hydrogen  is  produced  in  the  bowels,  or  more  rarely  in  the 
stomach  ;  and  that  when  leguminous  foods  containing  much 
cellulose  have  been  eaten,  marsh  gas  and  hydrogen  are  evolved 
on  a  quite  extensive  scale. 

As  you  know,  those  who  concern  themselves  with  the  dis- 
orders of  children  have  lately  been  at  pains  to  distinguish 
between  the  putrefactive  and  the  fermentative  organisms, 
associating  the  former  with  decomposition  of  proteid  food* 
and  the  latter  with  that  of  carbohydrates  ;  recognizing,  more- 
over, the  putrefactive  process  as  inhibitory  of  the  fermenta- 
tive. So  that  one  has  to  be  a  little  careful  in  the  use  of  words. 
But,  speaking  broadly,  we  admit  a  group  of  cases  in  which 
there  is  production  of  gas  in  the  stomach  and  bowels  as  a 
result  of  disintegrative  processes  due  to  microbic  activity. 
Sometimes  there  is  gross  error  in  diet ;  sometimes  there  is 
special  importation  of  special  organisms  ;  but  in  any  case  an 
atonic  condition  of  the  digestive  organs  is  present,  and  con- 
siderable delay  in  the  passage  of  food  from  the  stomach,  so 
that  the  organ  becomes  dilated.  There  is  a  vicious  circle  ; 
atony  and  deficient  juices  favour  fermentation  ;  gas  produc- 
tion distends  the  stomach  and  sets  up  dilatation.  And  the 
gas  that  is  eructated  is.  as  the  patient  will  say,  neither  odour- 
less nor  flavourless.     It  may  even  be  inflammable. 

But  there  are  the  cases,  not  so  easily  disposed  of,  where 
neither  yeast  nor  the  Bacillus  butyricus  occurs  in  the  stomach 
contents,  and,  rather  curiously,  even  lactic  acid  is  not  always 
present.  Such  cases  fall  into  two  groups  :  one  called  "  neu- 
rotic," with  which  I  am  most  concerned  ;  and  another,  that 


FLATULENCE  9 

I  will  call  "  dietetic."  In  the  first  the  gas  is  almost  always 
odourless  and  flavourless  ;  in  the  second  the  odour  or  flavour 
is  that  of  the  food  that  has  been  taken.  In  neither  is  there 
odour  or  flavour  suggestive  of  fermentative  or  putrefactive 
bye-products.  How  many  of  us,  normally  eupeptic,  do  not 
sometimes  suffer  after  a  meal,  perhaps  a  little  more  hearty 
than  usual,  and  into  which  certain  articles  of  diet  have  entered 
disparately,  from  some  temporary  distension  and  eructation^ 
that  does  not  recur  if  the  cause  of  offence  be  avoided  ?  Is  it 
credible  that  such  flatulence  is  due  to  a  special  microbic  infec- 
tion, and  fermentation  of  the  stomach  contents  ?  Of  course, 
if  dietetic  irregularities  continue,  if  the  stomach  begin  to 
weaken,  if  the  teeth  be  carious  and  the  gums  suppurate,  a 
bacterial  decomposition  may  be  superimposed  ;  but  I  speak 
of  the  ordinary  flatulence  that  occurs  when  potatoes,  peas, 
or  beans  are  taken  in  relative  excess,  and  which  may  be  dis- 
posed of  by  a  single  belch.  What  is  the  source  of  the  gas  ? 
Not  bacterial  activity  ;  for  there  is  no  culture  that  will  produce 
any  volume  of  gas  in  the  course  of  half  an  hour.  Indeed, 
ordinary  stomach  contents  may  be  kept  for  hours  in  vitro 
before  gas  formation  takes  place.  It  is  likely  that  the  mech- 
anism which  is  at  work  in  purely  "  neurotic  "  cases  has  some- 
thing here  also  to  do,  though  not  preponderatingly  ;  but  I  wish 
to  point  out  that,  just  as  cases  in  the  first  group  are  admittedly 
benefited  by  antiseptics  and  by  mineral  acids,  though  not 
relieved  by  the  administration  of  alkalies,  so  those  in  this 
"  dietetic  "  group  are  not  notably  helped  by  antiseptics  as 
such — are  certainly  not  helped,  as  a  rule,  by  acids  and  pepsin — 
but  are  relieved  by  the  administration  of  alkalies  after  meals. 
They  are  sometimes  called  "  acid  dyspepsias."  But  you  do 
not  find  butyric  acid  in  the  stomach  contents,  although  you 
feel  you  ought  to ;  and,  indeed,  one  is  almost  inclined  to  say 
that  some  of  these  cases  of  acid  dyspepsia  are  so  called  rather 
because  they  are  reheved  by  post-prandial  alkalies  than  for 
any  other  reason.  It  has  seemed  to  me  that  these  occasional 
flatulences  following  dietetic  indiscretion  are  connected,  not 
with  actual  hypersecretion  of  hydrochloric  acid,  but  rather 
with  what  one  may  call  "  relative  hyperchlorhydria."  That  is 
to  say,  the  normal  combination  of  the  hydrochloric  acid  with 
the  albumin  does  not  occur ;  and  an  interesting  point  is  that 
Hoppe-Seyler  long  ago  declared  the  evolution  of  hydrogen 
and  of  marsh  gas  from  food  containing  cellulose  to  be  aug- 


10  FLATULENCE 

merited  by  the  presence  of  hydrochloric  acid,  the  very  sub- 
stance that  is  lacking  in  the  fermentations  of  chronically 
dilated  stomachs.  At  any  rate,  it  seems,  from  the  purely 
clinical  point  of  view,  that  in  these  occasional  flatulencies 
which  are  not  simply  neurotic,  and  which  are,  with  equal 
certainty,  not  due  to  the  B.  hutyricus — which  are  relieved 
by  post-prandial  alkalies,  and  which  may  be  "  cured  "  by 
attention  to  diet — there  is  some  derangement  of  the  normal 
mechanism  of  digestion  that  is  not  yet  manifest.  I  would 
suggest  that  opportunity  be  taken  to  examine  carefully  the 
stomach  contents,  both  gaseous  and  liquid,  in  some  of  these 
cases  of  "  dietetic  flatulence  "  that,  at  the  risk  of  repetition, 
I  say  do  not  fall  either  into  the  purely  neurotic  category  or 
in  that  where  there  is  definite  dilatation  and  retention.  It  is 
possible  that  the  explanation  is  chemical  rather  than  bacterio- 
logical ;  perhaps  enzymosis  is  involved. 

Concerning  the  complex  group  of  flatulencies  in  which  the 
"  neurotic  "  or  "  nervous  "  element  is  generally  admitted,  the 
experience  of  physicians  seems  curiously  unequal.  Yet  one 
clinical  value  they  have  in  common  :  they  are  not  appre- 
ciably relieved  by  alkalies,  or  always  by  dieting.  Antiseptics 
and  lavage  are  seldom  of  avail. 

Some  cases  are  in  the  old,  others  in  the  young  ;  some  in 
sober  men,  others  in  silly  girls  ;  some  of  the  patients  are  nor- 
mally eupeptic,  others  habitually  dyspeptic  ;  a  few  of  them 
have  organic  disease,  others  are  sound.  Some  cases  occur 
after  shock,  others  after  operation,  or  during  convalescence 
from  acute  specifics,  and,  very  curiously,  not  a  few  during 
pneumonia.  Many  either  have,  or  afterwards  develop,  acute 
duodenal  or  pyloric  ulcer. 

Sometimes  there  is  great  distension  of  the  abdomen,  and 
death  ensues.  But  the  common  denominator  is  eructation,  or, 
as  some  would  say,  the  seeming  eructation  of  odourless  and 
flavourless  gas.  The  first  attack  may  be  sudden  and  of  great 
violence.  Sometimes  there  is  a  spell  that  lasts  for  a  day  or 
two,  but  without  return.  Sometimes  the  eructation  or  quasi- 
eructation  continues,  almost  without  intermission,  for  days 
at  a  time.  Sometimes  it  is  periodic  or  recurrent.  Sometimes 
it  is  associated  with  migraine.  Sometimes  it  follows  an 
accident,  or  may  be  reckoned  a  part  of  traumatic  neuras- 
thenia. Sometimes  it  seems  to  stand  in  relationship  with 
tea    or    tobacco.      Sometimes    it    follows   "  mental  shock." 


FLATULENCE  ii 

And,  though  I  do  not  wish  to  spend  time  on  the  cases 
of  meteorism  and  tympanites  that  are  seen  in  surgical 
wards,  it  is  obvious  that  there  is  an  intimate  relation 
between  gas  in  the  bowels  and  gas  in  the  stomach.  Indeed, 
the  amazing  thing  is  that  this  "  neurotic  flatulence,"  or  these 
forms  of  neurotic  flatulence  (if  I  may  use  the  phrase  without 
begging  any  question),  occur  under  so  many  different  circum- 
stances that  probably  none  but  those  whose  experience  has 
been  promiscuous  appreciate  its  significance.  It  is  only  thus 
I  can  explain  the  diverse  views  held  by  those  whose  experience, 
great  in  particular  directions,  has  yet  been  curiously  restricted 
in  others.  Those  who  have  once  lost  a  patient  by  death,  after 
a  hasty  diagnosis  of  "  air- swallowing,"  are  a  little  chary  of 
prognosis  ever  after.  Those  who  have  themselves  suffered 
(and  to  them  I  extend  my  sincere  sympathy)  know  how  diffi- 
cult it  is  to  obtain  really  helpful  advice.  The  subject  stands 
in  need  of  elucidation,  and  there  are  two  ways  in  which  we 
may  attack  it.  One  is  to  group  cases  according  to  their  clinical 
associations  ;  the  other,  to  clarify  our  notions  as  to  the  sources 
of  the  gas  that  distends  the  stomach,  or  is  eructated,  or  seem- 
ingly eructated,  and  then  to  connote  our  conclusions  with 
the  various  clinical  associations.  Now,  of  the  two  kinds  of 
explanation  put  forward,  one  suggests  that  the  gas  is  produced 
in  the  stomach  (or  bowels)  ;  the  other,  that  only  air  is  swal- 
lowed or  spuriously  eructated.  To  me  it  seems  that  there  is 
some  force  in  both  explanations — that  they  are  not  necessarily 
and  always  opposed. 

You  will  agree  that  when,  to  take  an  extreme  case,  a  fasting 
person  drinks  a  cup  of  tea,  and  within  a  few  minutes  is  in 
such  distress  from  abdominal  swelling  that  he  loosens  his 
clothes  and  pants  for  breath,  while  eructation  sets  in  and 
continues  for  hours,  all  notion  of  microbic  fermentation  must 
be  discarded.  Nor  can  sudden  fermentation  explain  the 
belching  of  gas  that  may  terminate  a  bout  of  angina  pectoris. 
I  do  not  say  that  mixed  cases  never  occur,  but  for  the  moment 
we  must  set  the  microbic  fermentations  on  one  side.  So,  too, 
must  we  set  on  one  side  the  dietetic  flatulencies  relieved  by 
alkalies,  in  which  some  chemical  process  may  be  at  work.  We 
must  concentrate  on  those  in  which  the  so-called  "  nervous  " 
spasmodic,  hysterical,  paralytic,  or  emotional  element  pre- 
dominates. 

It  does  not  follow,  because  we  dismiss  both  the  microbic 


12  FLATULENCE 

and  the  chemical  hypotheses,  that  we  are  bound  to  fall  back 
on  the  notion  that  the  eructated  gas  is  either  air  that  has  been 
swallowed,  or  only  seemingly  swallowed.  We  have  an  alter- 
native :  that  the  gas  is  produced  in  the  stomach,  but  by  a 
process  of  actual  secretion.  This  is  the  doctrine  of  pneimia- 
tosis :  unfashionable  nowadays,  though  old.  The  classic 
reference  is  in  that  lecture  on  dyspepsia  wherein  Graves  tells 
us  how,  in  1823,  he  read  an  essay  before  the  King  and  Queen's 
College  of  Physicians,  in  which  he  pointed  out  the  "  true 
source  of  the  acidity  and  flatulence  observed  in  dyspepsia, 
and  proved,  contrary  to  the  accepted  opinions,  that  it  was  the 
result  of  a  morbid  secretion."  In  fact,  he  says  :  "  I  showed 
that  the  stomach  has  the  power,  when  in  health,  of  secreting 
acids  and  air,  essentially  necessary  for  the  solution  of  the 
alimentary  mass,  and  proved  that,  in  dyspepsia,  this  power  is 
morbidly  deranged  in  such  a  manner  as  to  give  rise  to  a  super- 
secretion  of  acids  and  air." 

It  must  be  acknowledged  that,  though  Graves  believed  the 
normal  and  effective  acidity  of  the  stomach  to  be  due  to 
lactic  acid  (and  not  to  hydrochloric,  as  now  af&rmed),  he 
clearly  recognized  what  we  did  not  till  lately  know — that 
many  gastric  disorders  are  due  to  hypersecretion  of  the 
normal  acid  of  the  gastric  juice.  I  hesitate  to  hint  it,  but 
are  we  quite  certain  that  the  traces  of  lactic  acid  sometimes 
found  in  the  contents  of  healthy  stomachs  are  no  indication 
that  lactic  acid  may  be  an  accessory  factor  in  normal  diges- 
tion ?  The  absence  of  lactic  acid  in  hyperchlorhydria 
rather  suggests  that  we  ought  not  always  to  look  on  lactic 
acid  as  a  morbid  constituent  of  stomach  contents,  like  pus 
or  blood.  At  any  rate,  we  all  know  that  sour  milk  may  be 
a  very  present  help  in  time  of  hyperchlorhydria.  This  is, 
however,  a  digression. 

Trousseau  adopted  Graves's  theory  of  pneumatosis.  He 
said  :  "  Flatulent  dyspepsia  is  characterized  by  the  secre- 
tion in  excessive  quantity  of  the  gases  which  are  normally 
developed  in  the  intestinal  canal.  Immediately  after  the 
ingestion  of  food  these  gases  are  produced,  more  or  less 
abundantly,  in  the  stomach  and  intestines,  which  they  dis- 
tend ;  and  this  distension  leads  to  such  increase  in  size  of 
the  abdomen  as  obliges  the  patients  to  loosen  their  clothes. 
An  attempt  has  been  made  to  explain  this  phenomenon  by 
supposing  that  there  takes  place  a  rapid  fermentation  of  the 


FLATULENCE  13 

ingested  feculent  substances  ;  that  there  is  a  production  of 
carbonic  acid  gas,  the  result  of  a  fermentation  in  the  intestinal 
digestive  canal  exactly  similar  to  that  which  occurs  in  a  wine- 
maker's  mash-tub.  Matters  do  not,  however,  proceed  after 
that  fashion.  As  Graves  remarked,  persons  subject  to  flatu- 
lence have  gas  developed  in  the  intestinal  canal  with  almost 
equal  rapidity,  whether  they  eat  food  that  they  can  ferment 
or  whether  they  confine  themselves  to  almost  exclusively 
animal  aliment.  In  the  latter  case,  one  cannot  say  that  there 
has  been  fermentation.  That  some  gas  is  always  produced 
from  the  alimentary  mass  during  digestion  is,  however,  a  fact 
which  is  certain  ;  but  the  principal  source  of  the  gas  is  secre- 
tion from  the  alimentary  canal.  A  proof  that  this  secretion 
is  independent  of  the  coction  of  the  elements  is  afforded  by 
the  fact  that  an  hysterical  woman  will  sometimes  become 
tjmipanitic  in  ten  minutes.  Under  our  very  eyes  and  hands 
we  see  and  feel  the  abdomen  attain  a  great  size.  Consequently 
the  formation  of  gas  is  the  result  of  disturbance  of  the  nervous 
system,  an  increased  secretion  taking  place  in  exactly  the 
same  way  that  there  is,  under  similar  influence,  an  increased 
secretion  of  tears,  saliva,  or  urine." 

Furthermore,  "  this  flatulence  may  occur  when  the  stomach 
is  empty,"  and  "  while  measures  prescribed  on  the  fermenta- 
tion notion  are  useless,  baths,  cold  effusions,  and  ether  are 
all  useful." 

If  one  may  speak  with  any  disrespect  of  such  giants  as 
Graves  and  Trousseau,  it  is  obvious  that,  whatever  we  think 
of  the  notion  of  gas  secretion,  both  attempted  to  prove  too 
much.  Yet  it  is  interesting  to  note  that  by  implication 
Trousseau  recognized  three  kinds  of  cases  in  which  flatulence 
may  arise — those  in  which  there  is  fermentation,  those  in 
which  there  is  excessive  gas-forming  during  "  coction,"  and 
the  "  nervous  "  or  "  secretory "  cases.  Trousseau's  first 
group  corresponds  to  that  in  which  we  now  admit  microbic 
fermentation.  The  cases  of  excessive  gas  formation  during 
coction  may  be  identified  with  those  I  have  called  "  dietetic  "; 
the  third  group  is  that  which  I  have  called  "  nervous." 

It  is  interesting  to  note,  by  the  way,  that  Grayson  has 
suggested  recently  that  gas  is,  as  Trousseau  and  Graves 
believed,  produced  normally  during  digestion. 

But  the  epoch  that  succeeded  Trousseau's  was  a  materiaHstic 
one  :  it  was  that  of  the  great  German  chemists  and  biologists 


14  FLATULENCE 

— of  Liebig  and  of  others — and  the  notion  of  normal  or  ab- 
normal secretion  of  gas  under  nervous  influences  was  dropped. 
Well,  the  great  era  of  "  fermentation,"  and,  later,  of  bacterial 
action,  set  in  ;  and  if  any  poor  clinician  hinted  that  there  were 
patients  whose  cases  were  not  thus  to  be  explained,  he  was 
told  that  such  were  wretched  hysterics.  As  time  went  on, 
however,  it  was  felt  by  a  few  that  this  attitude  of  Podsnappery 
was  hardly  just,  and  the  doctrine  of  aerophagy  was  revived. 
Now,  the  doctrine  of  aerophagy  lays  it  down  that  the  disten- 
sion is  due  to  air  that  has  been  swallowed,  and  is  eructated 
on  occasion  ;  or,  in  the  alternative,  as  the  lawyers  say,  that 
there  is  no  distension,  and  the  air  is  not  really  swallowed,  but 
is  gulped  backwards  and  forN^^ards  in  the  throat.  Of  this  doc- 
trine Dr.  WyUie  of  Edinburgh  is  an  able  exponent,  and  a  dis- 
cussion of  his  views  is  imperative.  But  for  myself,  I  do  assert 
that  there  is,  in  a  good  many  cases,  actual  pneumatosis,  or 
secretion  of  gas  from  the  stomach.  That  the  practice  of  aero- 
phagy in  some  form  or  another  exists  is  true,  but  sometimes 
it  is  a  habit  induced  by  the  presence  of  gas  in  the  stomach, 
and  sometimes  it  is  purely  mimetic.  In  explaining  this  phe- 
nomenon of  flatulence  we  have  not  to  pin  our  faith  to  fer- 
mentation, or  to  gas  secretion,  or  to  aerophagy  as  a  suf&cient 
explanation  of  aU  cases,  but  to  distinguish  the  degrees  in 
which  each  of  these  processes  may  obtain.  Yet,  just  as 
Graves  went  to  one  extreme  in  ascribing  all  flatulencies  to 
secretion,  and  the  great  chemists  went  to  the  other  in  saying 
all  worth  notice  are  due  to  fermentation,  so  Dr.  Wyllie  goes 
too  far  in  suggesting  that,  whenever  air  swallowing  or  gulping 
occurs,  no  gas  is  being  produced  in  the  stomach. 

Some  may  think  the  notion  of  air  secretion  fantastic  ;  but 
let  us  see  on  what  basis  it  may  rest  before  we  consider  Dr. 
Wyllie's  views. 

My  interest  in  the  subject  dates  back  to  conversations  of 
years  ago  with  Dr.  Muir  Evans,  of  Lowestoft,  who  used  to 
express  his  disbelief  that  cases  of  sudden  tympanitic  disten- 
sion could  be  due  to  either  fermentation  or  to  air  swallowing. 
He  has  made  some  valuable  investigations,  to  which  I  will 
presently  refer ;  but  what  has  chiefly  struck  me  is  his  reference, 
in  support  of  the  idea  that  gas  can  be  secreted  from  the 
stomach  wall,  to  the  swimming-bladder  of  fishes.  Now,  this 
point  cuts  the  ground  from  beneath  the  feet  of  those  hard- 
headed  persons  who,  a  priori,  deny  the  possibility  of   gas 


FLATULENCE  15 

secretion.  Gas  exchange  is,  of  course,  admittedly  physio- 
logical. Now,  although  in  some  fishes  the  swimming-bladder 
is  used  as  a  lung,  in  many  of  the  Teleostei  its  function  is  that 
of  a  float  ;  and  it  is  provided  with  a  mechanism  whereby  gas 
is  produced  by  secretion,  and  not  by  mere  diffusion.  This 
secretion  of  gas  has  been  shown  by  experiment  to  be  controlled 
by  branches  of  the  vagus  and  sympathetic  nerves  "in  an 
exactly  similar  fashion  to  the  secretion  of  saliva  in  a  sali- 
vary gland."  Moreover,  the  swimming-bladder,  whether 
homologous  with  the  lung,  as  some  believe,  or  not,  arises  in 
Teleostei  as  a  diverticulum  of  the  gut  wall,  and  is  supplied  with 
blood,  not  from  the  aortic  arches,  but  from  branches  of  the 
dorsal  aorta.  Its  blood-supply,  then — and  the  point  is  not 
without  relevance — corresponds  with  that  of  the  human 
stomach. 

It  might  be  thought  that  the  question  whether  the  eructa- 
tions of  "  neurotic  "  patients  are  secreted  gas  or  swallowed 
air  could  be  immediately  settled  by  analysis.  But  this  is  not 
so,  for  the  gaseous  contents  of  what  may  be  thought  a  normal 
stomach  are  equivalent  to  atmospheric  air  in  which  the  oxygen 
is  entirely  replaced  by  carbonic  acid  ;  so  that  even  those  who, 
like  Dr.  Wyllie,  hesitate  to  admit  that  in  health  or  disease  the 
stomach  wall  can  secrete  gas,  are  compelled  to  acknowledge 
that  at  any  rate  the  stomach  can  exchange  carbonic  acid  for 
oxygen.  Dr.  Evans,  who  has  made  many  analyses,  maintains 
that  some  of  the  nitrogen  in  normal  stomach  gas,  as  well  as 
in  nervous  eructations,  is  given  off  from  the  blood,  and  that 
some  of  the  carbonic  acid  may  be  secreted  otherwise  than  in 
mere  exchange.  He  has  certainly  shown  that  we  have  no 
right  to  assume  that  the  nitrogen  is  derived  directly  from  the 
air,  since,  in  the  sound  of  the  codfish,  this  gas  occurs  in  the 
proportion  of  85  per  cent,  or  so  by  volume,  without  any  ques- 
tion of  its  production  otherwise  than  by  secretion.  I  am  not 
concerned  to  labour  the  details  of  gas  analysis,  for  since  Dr. 
Hutchison  admits  that  the  hypothesis  of  gas  secretion  from 
the  stomach  is  not  disproven,  and  I  can  find  no  other  that  is 
adequate,  I  am  inclined  to  think  that  the  weight  of  evidence  is 
in  its  favour.  The  ultimate  mechanism  of  this  gas  secretion 
is  another  point  on  which  two  American  physicians — Drs. 
Woodgate  and  Graham — have,  I  believe,  done  some  experi- 
mental work,  though  I  have  not,  as  yet,  been  able  to  obtain 
any  complete  account.    But,  before  passing  to  this  and  a 


i6  FLATULENCE 

consideration  of  the  doctrines  of  aerophagy,  some  brief  cita- 
tions from  current  textbooks  that  will  serve  to  show  the 
dearth  of  leading  that  we  have  on  the  subject  may  not  be 
without  interest. 

Sir  William  Osier  does  not  discuss  the  general  significance 
of  flatulence,  but,  using  the  words  "  nervous  eructations  " 
and  "  aerophagia  "  as  synonymous,  says  that  the  "  hysterical 
nature  of  the  affection  is  sometimes  testified  to  by  the  occur- 
rence of  several  cases  in  a  household."  Surely  one  might  as 
well  say  that  epilepsy  or  chorea  is  hysterical  because  mimetic 
cases  occur  in  a  household.  But  he  goes  on  to  declare  :  "  The 
expelled  gas  in  these  cases  is  atmospheric  air,  swallowed  or 
aspirated  from  without.  Sometimes  the  whole  process  may 
be  clearly  observed,  but  in  other  instances  the  act  of  swallowing 
may  he  almost  or  quite  imperceptible." 

Sir  Lauder  Brunton  exhibits  all  the  resource  of  the  Scots 
minister  who,  when  confronted  with  a  difficult  text,  looked 
it  boldly  in  the  face,  and  passed  on.  He  does,  however,  say 
that  sometimes  a  little  air  is  swallowed  with  food. 

Sir  Clifford  Allbutt  toys  gracefully,  as  is  his  wont,  with 
the  topic,  and  exhibits  all  his  literary  charm  and  command 
of  peregrinate  phraseology.  But  he  is  a  little  elusive.  He 
admits  that  with  tremendous  gusts  of  wind  there  may  be  no 
obvious  distension  ;  he  seems  to  agree  that  there  may  be — at 
least,  in  hysterical  subjects — some  source  of  wind  other  than 
decomposition  of  food.  He  says  it  is  possible  that  wind  may 
be  poured  into  the  alimentary  canal  from  its  own  walls.  But 
he  will  neither  aver  nor  deny  that  this  may  be  an  explanation 
of  the  strange  phenomena  sometimes  occurring  "  when  a  hard- 
working and  sensible  professional  man  will  wake  in  the  small 
hours  and  belch  forth  wind  boisterously  for  hours."  That 
hard  case  has  been  my  own,  and  I  confess  I  find  it  unsatisfying 
when  Sir  Clifford  goes  on  to  say  that  "  though  the  flatulence 
may  have  associated  with  it  disturbance  of  the  heart,  to 
follow  this  symptom  beyond  its  mechanical  causes  would 
lead  us  into  a  general  discussion  of  hysteria  and  neuras- 
thenia." 

A  most  pregnant  suggestion,  and  for  which  I  am  thankful : 
but  an  odd  excuse,  surely  ! 

Dr.  Soltau  Fenwick  comes  a  little  to  grips.  He  says  very 
little  is  known  concerning  the  escape  of  gases  from  blood  in 
the  walls  of  the  stomach,  but  he  admits  it  to  be  a  sound 


FLATULENCE  17 

clinical  observation  that  quantities  of  carbonic  acid  gas  are 
often  expelled  from  a  stomach  that  is  devoid  of  food  ;  and  he 
states,  without  comment,  that  the  contents  removed  from 
the  stomach  of  a  healthy  person  exhibit  no  signs  of  gas  forma- 
tion for  at  least  twenty-four  hours. 

Dr.  Frederick  Taylor  judiciously  says  that  flatulence  some- 
times develops  so  speedily  that  its  explanation  on  chemical 
grounds  is  difficult,  and  even  its  association  with  neurosis  does 
not  always  make  its  mechanism  clear. 

What,  now,  have  the  professed  aerophagists  to  say  ? 

Dr.  Wyllie,  their  protagonist,  after  giving  a  luminous  account 
of  that  flatulence,  arising  from  the  fermentation  of  food, 
which  he  calls  "  true  gastric  flatulence,"  goes  on  to  speak  of 
that  which  is  false — which,  in  other  words,  he  believes  to  be 
only  the  eructation  of  atmospheric  air  that  is  either  actually 
expelled  from  the  stomach  (after  having  been  introduced  into 
it  in  one  or  other  of  certain  ways),  or  that  is  only  seemingly 
so  expelled.  He  makes  allusion  to  the  classical  "  secretory  " 
theory,  and  admits  that  the  normal  stomach  has  the  power  of 
exchanging  carbonic  acid  gas  for  the  oxygen  of  intaken  air ; 
he  also  alludes  to  the  possible  production  of  gas  from  the 
stomach  walls  in  cases  of  failing  heart  with  pulmonary  con- 
gestion, as  if  by  a  kind  of  vicarious  respiratory  process. 
Moreover,  he  says  it  is  best,  for  the  moment,  to  consider  the 
question  of  the  secretion  of  gas  from  the  stomach  under 
nervous  influences  an  open  one.  But  he  clearly  does  not  be- 
lieve in  it ;  and  he  seeks  throughout  his  paper  to  establish  the 
predominant  influence  of  two  elements — hysteria  and  habit. 
His  observations  are  most  acute,  certainly ;  but  he  takes  no 
notice  of  the  hard-working,  and  I  hope  sensible,  professional 
men  like  myself,  who  give  Sir  Clifford  AUbutt  such  uneasy 
qualms,  and  who  have  an  unfortunate  habit  of  dying  just  after 
they  have  been  told  they  are  neurotic.  Nor  does  he  take  any 
heed  of  the  flatulency  in  angina  pectoris,  and  of  those  deaths 
that  are  ascribed  to  that  cliche  of  the  coroner's  court — pressure 
of  the  stomach  on  a  fatty  heart.  He  does  not  explain  the  case 
of  ileus  or  that  of  volvulus  ;  but  he  distinguishes  three  varieties 
of  false  flatulence — air  gulping,  air  swallowing,  and  air  suction. 

Air  gulping  is  a  process  by  which  air  is  introduced  into  the 
oesophagus  by  application  of  the  tongue-tip  to  the  teeth,  as 
in  pronouncing  the  letter  T,  the  cavity  of  the  mouth  and 
pharynx  being  filled  with  air  from  the  larynx,  while  shut  off 


i8  FLATULENCE 

from  the  nares  by  elevation  of  the  palate,  and  from  the  larynx 
by  closure  of  the  glottis.  Dr.  Wyllie  says  that  the  air,  while 
thus  shut  off,  is  put  under  strong  and  sudden  compression  by 
elevation  of  the  larynx  and  the  dorsum  of  the  tongue,  and 
under  this  pressure  is  forced  into  the  oesophagus,  entering 
with  a  slight  noise.  The  subject  then,  making  a  slight  expira- 
tory effort  with  the  glottis  closed,  puts  pressure  on  the  oeso- 
phagus, and  expels  air  with  a  slight  sound  of  eructation.  Or, 
if  he  choose,  he  can  go  on  gulping  the  air  till  so  much  is  intro- 
duced into  the  oesophagus  that  it  finds  its  way  into  the 
stomach.  The  process  can  be  repeated,  and  it  then  seems  as 
if  long-continued  eructations  from  the  stomach  are  going  on. 
This  process  I  have  recognized  clearly  in  myself  and  in  others. 
But  one  point  Dr.  Wyllie  overlooks  :  the  air  in  the  mouth  and 
pharynx  is  shut  off  from  the  oesophagus  by  spasm  or  hyper- 
tonus  at  the  junction  of  the  pharynx  and  oesophagus.  This 
must  indeed  be  so,  else  "  strong  compression  "  would  not  be 
needed  to  drive  the  air  into  the  oesophagus ;  a  simple 
swallowing  movement  would  suffice. 

Now,  Dr.  Wyllie  thinks  that  quite  a  number  of  cases  of 
flatulence  can  be  explained  away  by  degrading  them  to  the 
level  of  habit  actions  of  this  nature.  I  do  not  deny  that 
some  of  the  neuro-mimetic  cases  may  be  thus  explained,  nor 
that,  if  the  subject  of  gas  production  in  the  stomach  contracts 
the  habit  of  air  gulping,  he  may  continue  it,  just  as  a  neurotic 
child  who  learns  eye-twitching  because  of  conjunctival  irrita- 
tion may  continue  it  as  a  tic  long  after  the  primary  source  of 
irritation  has  been  cured.  But  most  air  gulpers  contract  the 
habit  because  it  enables  them,  by  overcoming  oesophageal 
spasm,  to  eructate  gas  imprisoned  in  the  stomach.  Air 
gulping  is,  primarily,  a  semi-purposive  action  designed  to 
overcome  involuntary  spasm  either  at  the  pharyngeal  or 
the  cardiac  end  of  the  oesophagus,  or  both. 

True  air  swallowing,  however,  apart  from  the  swallowing 
of  inconsiderable  quantities  of  air  with  food,  is  another  affair. 
It  is  performed,  like  ordinary  swallowing,  by  the  aid  of  a 
wave  of  contraction  from  the  dorsum  of  the  tongue  backwards, 
and  is  not  opposed  by  oesophageal  spasm.  Though  babies 
brought  up  by  hand  may  suck  in  air  through  their  bottles, 
and  hand-reared  calves  are  said  by  veterinarians  to  become 
"  hoven  "  in  like  manner,  it  is  rather  a  rare  accomplishment, 
like  wagging  one's  ears,  and  not  really  relevant  to  the  present 


FLATULENCE  19 

discussion.  But  there  is  another  form  of  air  swallowing,  as 
Dr.  Wyllie  calls  it,  which  needs  analysis.  When  adult  cattle, 
in  feeding,  get  portions  of  turnip  arrested  in  the  gullet,  what 
is  known  as  "  choldng  "  supervenes.  The  rumen  becomes 
distended  with  air,  and,  unless  relief  be  afforded,  the  animal 
speedily  dies.  A  very  usual  plan  of  treatment  is  to  push  the 
lump  down  with  a  probang.  Now,  Dr.  Wyllie  says  that  the 
enormous  distension  of  the  rumen  with  gas  is  due  to  the  fact 
that  the  animals  make  convulsive  efforts  to  swallow  the  lump, 
and  in  so  doing  swallow  air,  which  gets  past  the  lump  into  the 
rumen.  This  may  or  may  not  be  so  ;  for  myself,  I  do  not  see 
how  the  air  can  get  past,  but  Dr.  Wyllie  finds  support  for  his 
notion  in  the  fact  that  some  Lowland  farmers  treat  choking 
animals  by  using  a  gag  or  bit  which  separates  the  jaws,  and 
in  the  observation  that  some  of  these  choking  animals  indulge 
in  a  kind  of  eructation  like  that  of  the  air  gulpers.  Now,  a 
great  many  veterinary  surgeons  think  differently — that  the 
gas  is  actually  produced  in  the  stomach — and  they  allege 
cogent  reasons.  Personally,  I  agree  with  them,  but  think  that 
the  oesophagus  becomes  applied  to  the  lump  by  spasm,  as  does 
the  urethra  to  a  catheter,  and  that  the  convulsive  swallowings 
and  gulpings  are  semi- purposive  attempts  to  inhibit  the  spasm. 
The  putting  of  the  bit  or  gag  in  the  mouth  inhibits  the  spasm, 
just  as  does  a  similar  procedure  have  similar  effect  when  anaes- 
thesia is  being  induced.  It  is  obvious  that  when  spasm  is 
inhibited,  and  proper  action  of  the  oesophagus  is  resumed,  the 
food  can  be  swallowed  easily.  Has  not  each  of  us,  when  a 
child,  had  a  lump  of  food  "  stuck  in  the  throat  "  successfully 
coaxed  on  by  swallowing  water  ?  And,  according  to  some 
veterinary  surgeons,  if  the  rumen  be  cut  into,  letting  out  the 
gas,  which,  as  they  believe,  is  secreted  from  the  stomach  wall 
under  nervous  influences,  the  spasm  may  be  overcome. 

There  is  one  other  kind  of  "  hoven  "  which  must  be  men- 
tioned :  it  is  the  case  of  those  animals  who,  after  feeding  on 
damp  clover,  get  enormous  distension,  and  die,  as  is  so  graphic- 
ally described  in  "  Far  from  the  Madding  Crowd."  Dr.  Wyllie 
refers  to  this,  but  does  not  explain  it,  as,  indeed,  I  do  not  see 
how  he  can,  on  his  air-swallowing  theory. 

We  have  now  discussed  air  gulping  and  air  swallowing. 
Air  suction  has  no  accessary  connection  with  the  stomach, 
as  everyone  accustomed  to  gynaecological  work  knows.  When 
a  Sims'  speculum  is  passed  on  a  fat  woman,  or  the  vagina  is 


20  FLATULENCE 

opened,  with  the  patient  in  the  Trendelenburg  position,  air 
rushes  in  with  a  squelch  as  negative  pressure  comes  into  play. 
Barry,  too,  has  reported  cases  of  air  entering  the  bladder, 
almost  audibly,  in  women  with  lax  muscular  tone  while  walk- 
ing about.  This  is  air  suction.  But  in  horses  who  are  crib- 
biters,  as  in  some  human  beings,  it  is  brought  about,  in  respect 
of  the  oesophagus,  by  fixation  of  the  inspiratory  muscles, 
resulting  in  negative  pressure  which  opens  it,  and  allows  air 
to  enter.  Air  thus  introduced  into  the  oesophagus  may  be 
passed  into  the  stomach,  or  "  expelled  with  machine-like 
regularity  and  a  kind  of  sob."  The  trick  is  easily  learned. 
The  jaw  is  thrust  out,  and  the  larynx  elevated.  A  deep  breath 
is  taken.  When  tension  is  relaxed,  the  air  is  let  out  with 
"  eructation."  A  biggish  or  emphysematous  chest  and  a  lax 
tone  of  the  involuntary  muscles  seem  to  help  in  the  accom- 
plishment, just  as  in  the  gynaecological  analogue.  Dr.  Wyllie, 
with  admirable  consistency,  looks  on  air  suction  as  a  sort  of 
habit,  or  vice,  as  grooms  say.  But  it  is  not  always  so.  It 
may  be  an  involuntary  accompaniment,  in  the  type  of  person 
I  have  described,  of  that  curious  physical  sign  of  profound 
attention  noted  by  Ribot — the  holding  of  the  breath.  At 
other  times,  as  in  a  case  mentioned  by  Dr.  Mackenzie,  it  seems 
associated  with  such  muscular  effort  as  walking  up  a  hill  when 
the  breath  is  held  and  the  mouth  is  opened.  But,  of  course, 
habit  may  easily  be  established. 

The  position,  however,  that  I  would  take  up,  after  some 
curious  personal  experiences  and  the  observation  of  a  good 
many  patients,  is  that  in  flatulency  we  may  have  to  deal  with  : 

1.  Disintegrating  processes,  due  to  micro bic  activity. 

2.  Such  cases  as  Trousseau  thought  due  to  excessive  gas- 
production  during  coction,  and  which  are  perhaps  dietetic, 
chemical,  or  enzjmiotic. 

3.  Gas  "  secretion  "  from  the  walls  of  the  stomach  or  bowels. 

4.  Gas  secretion  to  which  air  gulping  is  added,  to  overcome 
the  spasm  that  prevents  eructation. 

5.  Cases  in  which  air  gulping  occurs  as  a  trick  accidentally 
learned  :  as  a  form  of  neuro-mimesis  ;  or  as  a  manifestation  of 
hysteria,  in  association  with  globus  hystericus. 

6.  True  air  swallowing,  in  babies  fed  from  a  defective 
apparatus;  and  occasionally  in  adults. 

7.  Air  suction,  analogous  to  the  suction  of  air  into  the 
vagina  or  bladder,  occurring  in  persons  with  hypotonus  of 


FLATULENCE  21 

involuntary  muscle,  and  under  circumstances  that  fix  the 
respiration.  This  also  may  be  continued  as  a  habit,  possibly 
alternative  to  air  gulping. 

It  is  really  with  the  third  and  fourth  classes  only  that  I  wish 
now  to  deal,  for  these  have  points  of  clinical  and  physiological 
importance  in  common,  and  it  is  they  that  give  rise  to  the 
difficulties  of  practice. 

By  great  good  fortune,  only  the  other  day  I  came  across  an 
article  by  Mr.  Begg  (a  veterinary  surgeon  who  practises  in 
Lanark)  dealing  with  "  hoven  "  or  "  choking  "  in  cattle.  Mr. 
Begg  evidently  believes  that  the  gas  is  really  produced  in 
some  way  or  another  in  the  rumen  ;  sometimes,  perhaps,  by 
fermentation,  and  sometimes  not.  He  does  not  discuss  how 
or  why  it  should  be  produced  ;  his  aim  is  purely  clinical,  or 
stabular,  as  I  suppose  one  should  say.  But  he  distinguishes 
two  types  of  "  hoven."  The  one  is  the  classical  kind,  where  a 
lump  is  impacted  in  the  oesophagus.  In  this  he  says  that  the 
gas  goes  on  being  emitted  rhythmically  after  the  obstruction 
is  removed  ;  and,  if  the  obstruction  cannot  be  at  once  pushed 
down,  he  recommends  opening  the  rumen — doing  a  gastros- 
tomy, in  fact.  These  points  seem  clearly  on  my  side,  and  not 
on  Dr.  Wyllie's.  The  other  type  is  represented  by  what  occurs 
when  animals  have  a  debauch  of  damp  aftermath  of  clover ; 
then  the  gas  is  intimately  mixed  with  the  mass  of  fodder,  and 
is  not  evacuated  easily  by  mere  puncture  of  the  rumen. 
This  seems  rather  to  suggest  "  coction,"  or  some  rapid 
enz57motic  change ;  but  Mr.  Begg  goes  on  to  remark 
that  cases  conforming  more  or  less  to  one  or  other  type  are 
also  apt  to  occur  (i)  when  an  animal  has  eaten  poisonous 
plants  ;  {2)  after  exposure  to  chill ;  (3)  when  sudden  feeding 
follows  fasting  or  over-driving ;  (4)  after  taking  of  very  cold 
water :  and,  inclusively,  in  animals  predisposed  to  indigestion. 
Finally,  it  is  laid  down  as  a  general  law  that  the  particular 
condition  of  the  animal  may  he  a  major  factor  in  the  presence 
of  the  less  potent  of  the  recognized  causes.  This  seems  to  me 
an  admirable  statement  that  we  may  apply  directly  to  human 
beings.  For  so-called  nervous  flatulence  occurs  when  there 
is  obstruction,  or  spasm  after  ingestion  of  certain  foods ;  as  a 
result  of  poisoning  from  tea  or  tobacco  ;  in  cases  of  shock, 
exhaustion,  or  exposure  ;  and  in  those  subject  to  previous 
dyspepsia.  And,  again,  the  particular  condition  of  individuals 
accounts  for  the  occurrence  cf  very  severe  symptoms,  when. 


22  FLATULENCE 

apparently,  only  the  less  potent  external  causes  may  be  at 
work.  If  to  this  we  add  the  recognition  of  purpose  in  air 
gulping,  we  have  very  nearly  covered  the  ground.  But  not 
quite :  for  distressing  flatulence  may  occur  under  some  other 
conditions.  Before,  however,  alluding  to  these,  I  must  return 
for  one  moment  to  the  question  of  oesophageal  spasm  in  its 
relation  to  air  gulping.  There  is  no  need  for  me  to  adduce 
the  work  of  Dr.  Hertz  and  others  in  proof  that,  with  various 
irritative  and  so-called  functional  disorders  of  the  stomach, 
spasm  may  occur  at  the  pylorus,  at  the  cardia,  or  midway 
indeed,  and  also  at  the  junction  of  the  pharynx  and  oesophagus. 
But  my  thesis  is  that,  given  the  production  of  gas  in  the 
stomach  otherwise  than  from  fermentation,  simple  or  multiple 
spasm  does  occur,  imprisoning  the  poured-out  gas.  The 
mechanism  of  the  spasm  is  probably  intimately  connected 
with  the  mechanism  of  the  gas  production ;  but  that  it  does 
occur  I  am  convinced.  I  once  was  fortunate  enough  to  get 
a  regular  air  secreter  and  gulper  examined  on  the  screen  during 
one  of  his  bouts.  We  gave  him  a  bismuth  drink — a  rather 
hazardous  proceeding  for  those  who  were  standing  by,  as  he 
was  spluttering  like  a  geyser — and  I  shall  never  forget  the 
radiologist's  bewilderment  as  he  saw,  first  a  stricture  at  the 
upper  end,  and  then  one  at  the  lower  end,  of  the  oesophagus. 
Of  course,  as  the  sequel  proved,  the  strictures  were  spasmodic 
only ;  but  the  fact  remains  that  there  is  spasm,  that  this 
spasm  prevents  the  eructation  of  the  gas,  and  that  the  air 
gulping  is  a  device  to  overcome  the  spasm.  It  gives  reUef, 
but  it  does  not  necessarily  stop  the  gas  production.  Hence 
the  need  for  repetition  of  the  act.  Should  anyone  have  doubt 
as  to  the  association  of  spasm  with  eructation,  I  would  ask 
him  to  read  a  paper  by  Meunier  on  its  occurrence  in  duodenal 
ulcer.  You  will  remember,  too,  how  when  a  patient  under  an 
anaesthetic  is  going  to  vomit,  he  first  of  all  swallows — an  auto- 
matic device  to  inhibit  the  spasm  that  is  keeping  back  the 
food  chucked  against  the  cardia  ;  and  you  will  agree  with  me 
that,  by  manipulating  the  jaw,  it  may  be  possible  to  stop  the 
threatened  vomiting.  But  opening  the  mouth  assists  vomi- 
tion,  just  as  does  Dr.  Wyllie's  use  of  the  gag,  which  he  has 
borrowed  from  the  farmers  and  applied  to  human  beings, 
inhibit  spasm  even  better  than  the  gulping  which  it  supplants. 
Dr.  Guthrie  Rankin  was  very  near  the  truth  when  speaking 
recently  of  the  wretched  people  with  neurotic  dyspepsia  who 


FLATULENCE  23 

indulge  in  air  swallowing  and  so  forth  to  obtain  fancied  relief 
from  their  sufferings.  But  one  might,  with  equal  wit,  speak 
of  the  wretched  neurotics  who,  when  deep  under  ether  and 
inclined  to  vomit,  persist  in  swallowing,  as  if  that  could  do 
them  any  good  ;  or  the  foolish  persons  who,  when  so  ill-advised 
as  to  have  acute  perforative  peritonitis,  insist  on  contracting 
down  their  recti  on  the  intestines — an  habit  most  annoying 
to  the  surgeon  in  attendance,  and  quite  futile  if  intended  as 
any  real  protection  to  the  leak. 

Setting  on  one  side  the  mimetic  cases,  and  admitting  that  in 
others  air  gulping  is  only  secondary,  it  remains  for  us  to  con- 
sider the  clinical  aspects  of  pneumatosis  itself  in  greater  detail. 

It  is  not  unseldom  found,  when  a  patient  comes  for  advice, 
that  the  first  attack  was  a  violent  and  very  distressing  one, 
and  that  subsequent  attacks  have  been  less  severe,  though 
more  prolonged.  And,  as  Sir  Clifford  Allbutt  has  pointed  out, 
often  they  disturb  the  patient  at  night,  and  persist  during  the 
small  hours.  Another  feature  is  the  not  infrequent  alteration 
of  other  secretory  functions  :  sometimes  little  urine  is  passed, 
even  for  days,  yet  when  the  attack  subsides  there  may  be  an 
abundant  flux  of  limpid  fluid,  as  after  hystero- epilepsy  and 
angina  pectoris.  Two  noteworthy  sources  of  distress  are 
cardiac  irregularities  and  dyspnoea.  It  is  usual  to  explain 
the  cardiac  irregularity  or  embarrassment  as  due  to  pressure 
of  the  distended  stomach  on  the  heart.  No  doubt  this  has 
its  importance,  but  it  is  a  mistake  invariably  to  attribute 
death,  when  it  occurs,  to  this  cause  alone.  For  I  would  remind 
you  that  death  does  occur  in  these  cases ;  even  Dr.  Wyllie 
describes  one  fatal  event,  wherein  the  stomach  was  so  dis- 
tended with  gas  that  the  peritoneum  was  actually  cracked. 
He  expresses  himself  as  frankly  puzzled  by  such  an  ending  to 
what  he  believed  to  be  a  simple  affair  of  air  gulping.  But  I 
have  seen  several  such,  and  on  the  occasion  of  my  own  first 
attack  was  for  some  little  time  in  a  very  distressed  condition. 

Another  source  of  cardiac  distress  is  imprisonment  in  the 
oesophagus  of  gas  escaped  from  the  stomach.  In  this  event, 
until  the  spasm  relaxes,  permitting  eructation,  the  patient 
may  be  very  uncomfortable  and  look  very  queer,  the  pulse 
becoming  very  irregular.  In  quite  a  number  of  cases  of  recur- 
rent flatulence  of  this  nature  there  is  arrhythmia  from  ven- 
tricular extra-systole.  In  the  absence  of  organic  change  in 
the  cardiac  apparatus,  it  seems  fair  to  regard  the  arrhythmai 


24  FLATULENCE 

as  cin  expression  of  the  underlying  neurosis,  and  not  as  a  mere 
consequence  of  the  gastric  distension  ;  it  is  certainly  the  truth 
that  these  cases  are  usual!}-  toxic  ones,  in  which  tea  and 
tobacco  play  their  part. 

Again,  there  are  cases  in  which  both  the  flatulence  and  the 
cardiac  affection  seem  to  form  part  of  what  Sir  Wilham  Gowers 
has  called  a  "  vaso- vagal  "  attack.  In  such,  in  mj^  own  ex- 
perience, there  is  often  a  tendency  to  bradycardia. 

For  nearly  twelve  years  I  have  known  a  gentleman  who, 
now  over  eighty,  is.  for  his  age,  one  of  the  most  ^ngorous 
men,  physicallj^  and  mentallj^  that  I  have  met.  His  pulse 
has  been,  for  the  last  twenty  or  thirty  years,  getting  slower 
and  slower.  Without  any  heart-block  whatsoever,  it  now 
beats  normally  about  fifty  times  a  minute.  But,  especially 
when  he  has  been  subjected  to  any  annoyance,  or  has  been 
exhausted  in  the  prosecution  of  the  public  duties  that  he  still 
performs,  he  gets  appaUing  bouts  of  gas  production,  and  his 
pulse  falls  even  to  forty  per  minute,  although  perfectly  regular. 
In  support  of  the  notion  that  this  is  due  to  vagal  neurosis,  I 
may  mention  that  about  six  years  ago,  when  convalescent  from 
a  basal  pneumonia,  this  gentleman  had  hiccough  which  lasted 
for  two  days  \\ithout  intermission. 

Yet,  again,  there  are  cases  in  which  there  is  actual  cardiac 
disease  associated  \^ith  flatulence.  To  one  group  Dr.  WyUe 
has  referred — that  of  persons  with  faiUng  compensation  to 
mitral  disorder — but  a  ver\-  important  class  is  formed  by  those 
who  have  angina  pectoris,  or  sometimes  what  is  known  as 
"  angina  abdominis."     Other  patients  have  aortic  disease. 

The  significance  of  flatulence  is,  in  these  conditions,  con- 
siderable. You  will  recollect  the  case  of  the  late  Premier, 
who,  one  night  after  making  a  long  speech,  was  seized, 
according  to  the  Press,  with  an  attack  of  flatulent  indigestion  ; 
but  he  died  of  heart  disease  a  few  months  later. 

Still,  by  a  sort  of  reciprocating  arrangement  between  the 
heart  and  stomach,  true  angina  pectoris  may  be  precipitated 
by  gastric  irritation ;  and  patients  who  are  the  subject  of 
veritable  angina  pectoris  may  have  minor  seizures  induced 
through  indiscretions  in  diet,  in  alternation  with  purely  cardio- 
pathic  ones.  And,  this  being  so,  it  is  not  surprising  to  meet 
with  such  cases  as  narrated  by  Dr.  Mackenzie,  of  people  with 
classical  heart-block,  whose  attacks  are  associated  with 
pneumatosis. 


FLATULENCE  25 

Some  neurasthenic  patients  with  flatulence  have  false 
angina.  These  are  toxic  cases,  as  a  rule,  where  tea  and  tobacco 
have  their  part.  And  I  would  remind  you  that  tea  and 
tobacco  may  be  taken  in  moderation  for  years,  and  yet,  quite 
suddenly,  if  the  patient  come  under  stress,  will  begin  to  exert 
so  marked  a  toxic  influence  that  the  cause  of  the  symptoms 
may  escape  recognition  because  the  excess  is  so  purely  rela- 
tive. Even  so  with  cattle ;  the  particular  state  of  the  beast 
allows  a  less  potent  cause  to  produce  exaggerated  effects. 

The  vaso- vagal  cases  must  be  connoted  with  those  flatu- 
lencies that  occur,  in  spite  of  careful  feeding,  during  pneu- 
monia ;  in  which  connection  I  would  refer  to  papers  by  Mr. 
Turner  and  by  Dr.  Neuhof .  And  there  are  the  cases  that  occur 
during  convalescence  from  acute  specific  diseases,  on  which 
Dr.  Campbell  Thomson  has  made  some  shrewd  remarks.  We 
have  not  yet  exhausted  the  possibilities.  There  are  cases  asso- 
ciated with  precedent  gastric  disorder ;  and  there  are  those 
into  which  the  element  of  shock  or  exhaustion  enters.  To 
take  the  last  first,  I  would  remind  you  that,  as  Mr.  Armour 
has  shown,  flatulent  distension  and  eructation  is  a  common 
manifestation  in  traumatic  neurasthenia.  But  it  has  relation 
to  trauma  apart  from  neurasthenia,  as  is  demonstrated  by 
the  occurrence  of  post-operative  tjntnpany,  and  such  cases 
as  that  of  a  steady,  sober,  healthy  gentleman  who  fell  into 
a  brook  one  night,  picked  himself  up,  went  home,  and  died 
in  a  fortnight  of  "flatulent  dyspepsia,"  with  no  lesion  that 
was  discoverable  at  the  post-mortem.  Such  a  case  has  a 
peculiar  bearing  on  the  question  of  shock,  but  it  must  suffice 
to  say  here  that  the  element  of  shock  cannot  well  be 
separated  entirely  from  the  fact  that,  just  as  the  overdriven 
and  chilled  cattle  most  easily  get  hoven,  so  it  is  harassed, 
overworked  professional  men,  as  well  as  silly  tea-drinking 
girls,  who  suffer  from  flatulence  with  which  there  is  asso- 
ciated no  cardiac  or  vascular  disease. 

Still,  in  human  beings,  as  in  cattle,  it  is  from  an  harassed 
stomach,  and  especially  from  one  which  is  subjected  to  ir- 
regular meals  and  to  meals  when  exhausted,  that  gas  produc- 
tion is  to  be  expected.  Even  a  telephonic  summons  may 
precipitate  an  effusion  of  gas  when  a  tired  man  is  at  the  table  ; 
mental  agitation  and  annoyance  have  their  share,  and  so  do 
certain  kinds  of  food.  At  the  same  time,  some  of  the  worst 
spells  I  have  ever  seen,  and,  moreover,  quite  uncontrolled  by 


26  FLATULENCE 

washing  out  or  by  antiseptics,  have  been  in  association  with 
malignant  disease  in  or  about  the  stomach.  In  all  these  the 
vagus  plays  its  part.  But  the  most  fascinating  connotation 
is  with  acute  duodenal  ulcer.  The  American  surgeons  (notably 
Starr)  admit  that,  if  we  delve  into  the  past  history  of  him  with 
duodenal  or  pyloric  ulcer,  we  get  an  account  of  neurotic 
dyspepsia.  And  Binnie  has  pointed  out  that  one  factor 
common  to  all  cases  of  duodenal  ulcer  is  vascular  change. 

And  Dr.  Herschell,  while  reckoning — I  think  wrongly — aero- 
phagy  as  purely  neurasthenic,  yet  admits  that  pnemnatosis 
or  gas  secretion,  associated  with  complaints  of  spasm  in  the 
throat,  does  occur  in  close  alliance  with  duodenal  or  pyloric 
ulcer.  I  would  say  this  :  that  quite  a  number  of  these  flatu- 
lent cases  that  go  on  for  weeks  at  a  time,  that  first  improve 
and  then  relapse,  ultimately  develop  chronic  ulcer  ;  and  there 
is  reason  to  believe  that  very  often  spells  of  flatulence  are 
associated  with  the  formation  of  an  acute  mucous  ulcer  that 
heals  up  and  breaks  down  again.  Neuhof  finds  an  intimate 
relation  between  the  occurrence  of  flatulence,  the  formation 
of  these  acute  mucous  ulcers  (as  Starr  calls  them),  and  irrita- 
tion of  the  vagus.  And  can  we  not  now  see  dimly  the  relation 
between  the  shock  of  a  bum,  the  acute  duodenal  ulcers  of 
burns,  and  the  flatulence  and  distension  that  so  commonly 
follow  extensive  skin  burns  ?     I  think  so. 

Though  all  subjects  of  pneumatosis  complain,  in  degree,  that 
they  cannot  get  their  breath,  j^et  it  is  often  noticeable  that 
there  is  no  real  dyspnoea.  Indeed,  in  the  very  worst  cases  of 
pneumatosis  the  breathing  may  be  infrequent  and  shallow, 
though  for  the  patient  the  sensation  of  airlessness  is  most 
distressing.  There  is,  too,  a  peculiar  restlessness  in  these 
graver  cases  which  I  now  recognize  as  equivalent  to  the  rest- 
lessness of  shock,  and  of  impending  death  in  diphtheria  when 
internal  respiration  is  abrogated. 

It  is  not  to  be  denied  that  the  actual  mechanical  impediment 
to  respiration  from  an  enormously  dilated  stomach  may  be 
very  great,  and  I  do  not  decline  to  admit  the  intrusion  of  the 
element  of  cardiac  distress.  But,  on  the  occasion  of  my  own 
first  and  most  severe  attack,  which  occurred  with  almost  ridicu- 
lous suddenness  during  convalescence  from  diphtheria,  the 
sensation  of  air  hunger  was  so  distressing,  and  yet  the  respira- 
tions were  so  slow  and  infrequent,  that  I  thought  my  respira- 
tory muscles  were  paralyzed. 


FLATULENCE  27 

I  now  recognize  the  relation  of  this  condition  to  what  is 
known  as  "  acapnia."  You  will  recollect  that  Henderson  of 
Yale  has  shown  how  there  is  a  definite  relation  between  shock, 
vaso-constriction,  and  that  condition  of  acapnia  in  which  there 
is  such  a  diminution  of  carbonic  acid  gas  in  the  tissues  and 
blood  that  the  respiration  is  slowed  until  the  carbonic  acid 
accumulates  up  to  stimulating  strength,  and  hyperpnoea  or 
dyspncea  returns.  I  do  not  say  that  all  Henderson's  deduc- 
tions will  be  maintained,  but  his  observations  are  acute. 
Now,  it  has  been  proved  by  Crile  that,  if  abdominal  viscera 
are  exposed  experimentally,  carbonic  acid  gas  is  given  off 
rapidly  from  them.  And  the  obvious  inference  is  that  in 
laparotomy  such  a  loss  of  carbonic  acid  gas  may  occur  in 
this  way  that  acapnia  is  produced,  and  may  be  a  factor  in 
death  under  the  anaesthetic ;  or  afterwards,  as  others  have 
shown. 

Though  Henderson  thinks  that  acapnia  is  a  cause  of  shock, 
I  am  more  inclined  to  think  that  it  is  a  part  of  "  shock," 
especially  since  Crile  has  shown  how,  if  the  displaced  viscera  be 
covered  with  omentum,  the  carbonic  acid  gas  is  not  given  off. 
It  is  interesting  to  note  that,  in  abdominal  operations,  Mr. 
Arbuthnot  Lane  covers  the  bowels  with  a  vaselined  silk  sheet, 
and  I  have  heard  it  said  that  his  shock  effects  are  remarkably 
slight.  But  I  ask  you,  if  carbonic  acid  gas  be  thus  given  off 
from  the  viscera  in  experiments,  is  it  ridiculous  to  suggest  that 
in  states  of  flatulency  it  is  given  off  into  the  Imnen  of  the 
viscus  ?  And  I  beg  you  to  note  this :  that  our  veterinary 
friend  at  Lanark  says  he  believes  "  hoven  "  cattle  die  of 
carbonic  acid  gas  poisoning,  and  not  of  heart  failure.  Since 
acapnia  leads  to  all  sorts  of  curious  asphyxial  consequences, 
he  is  at  least  on  the  right  track.  Let  us  agree  that  the 
gases  of  the  body  are  seriously  deranged  as  a  result  of  the 
pneumatosis,  and  he  comes  into  line  with  us  all. 

Acapnia,  moreover,  may  be  produced  by  forced  or  by  arti- 
ficial respiration.  So  we  can  understand  how  it  is  that  the 
hyperpnoea,  caused  by  the  mechanical  pressure  of  a  distended 
stomach,  may  help  to  induce  acapnia  and  its  consequences. 
And,  again,  a  lack  of  ox5^gen  without  excessive  carbonic  acid 
in  the  blood  sets  up  increased  tonus  of  the  circular  muscle 
fibres,  while  in  acapnia  the  tonus  is  lost.  I  now  realize  how 
it  was  that,  when  my  acapnia  became  extreme,  my  spasm 
relaxed,  and  up  came  the  wind  ! 


28  FLATULENCE 

The  key  to  the  understanding  of  these  many  different  condi- 
tions is  this  :  patients  with  true  angina  pectoris  get  flatulence 
and  eructations,  not  because  their  coronary  arteries  are 
sclerosed,  as  Held  has  suggested,  but  because  they  have 
sclerosis  of  their  cceliac  axis.*  We  do  not  often  examine  the 
state  of  the  branches  of  the  coeliac  axis  ;  but  I  have  been  pro- 
foundly impressed  by  a  case  of  my  own  in  which  the  patient, 
who  had  suffered  for  some  time  from  angina  abdominis  and 
flatulence,  developed  necrosis  of  her  pancreas,  and  died.  She 
had  a  very  degenerate  coeliac  axis,  and  her  pancreatic  artery 
was  blocked.  Dr.  Bernstein  tells  me  he  has  seen  this  several 
times.  I  put  it  to  you  that  where  there  is  chief  incidence  of  the 
disease  on  the  coronary  arteries,  the  case  will  pass  as  angina 
pectoris  ;  where  there  is  greater  incidence  on  the  coeliac  axis, 
the  case  is  one  of  angina  abdominis.  The  flatulence  in  either 
case  is  connected  with  "  intermittent  claudication  "  of  the 
gastric  arteries,  just  as  the  heart  pain  is  due  to  that  of  the 
coronaries.  For  we  must  admit  that,  in  addition  to  the  nar- 
rowing of  the  coronary  arteries  from  disease,  there  is  super- 
added, just  as  in  intermittent  claudication  of  the  legs,  either 
some  spasm  of  the  non-rigid  parts,  or,  at  least,  insufficiency 
of  the  blood-supply  for  the  occasion.  The  same  sort  of  thing 
occurs  in  the  brain,  as  Sir  William  Osier  has  shown  ;  and  Sir 
Lauder  Brunton  has  told  us  how,  in  migraine — which  I  remind 
you  is  often  associated  with  some  degree  of  flatulence — there 
is  recognizable  contraction  of  the  peripheral  branches  of  the 
temporal  artery.  But  migraine  is,  if  the  expression  be 
allowed,  only  the  functional  replica  of  the  headaches  of  arterio- 
sclerosis ;  and  a  functional  replica  of  true  angina — pectoris  aut 
abdominis — is,  in  measure,  to  be  found  in  the  flatulent  disturb- 
ances that  accompany  migraine.  I  find  it  hard  to  resist  the 
conclusion  that  the  underlying  mechanism  of  the  processes 
that  give  us  these  wind  storms  is,  in  part  at  least,  indicated 
by  spasm  or  insufficiency  of  the  arterial  vessels.  If  you 
like  to  apply  the  same  conclusions  to  ileus  and  to  meteorism, 
I  will  not  disagree,  although,  of  course,  fermentation  and 
putrefaction  have  their  share  of  the  blame  ;  for  Murphy  and 
Vincent  have  laid  it  down  that  interference  with  the  circula- 
tion is  a  vital  factor  in  the  production  of  ileus.  Certainly 
Stone,   Bernheim,  and  Whipple  think  that  some  unknown 

*  The  recent  remarks  of  Fiessinger,  and  of  Robin,  are  of  great 
interest.     (Acad,  de  Medecine:  S6ance  du  ler  Octobre,  1912.) 


FLATULENCE  29 

poison  is  at  work,  and  it  is  true  that  the  interference  with  the 
circulation  to  which  Murphy  and  Vincent  look  is  that  which 
follows  venous  congestion.  But  now  we  seem  in  touch  with 
Dr.  Wyllie's  admission  of  possible  gas  secretion  in  failing  mitral 
compensation.  An  essential  point,  however,  is  that  of 
oxygen-carrying,  and  the  suggestion  may  be  hazarded  that 
the  unknown  toxic  substance  that  Stone  and  his  colleagues 
have  failed  to  isolate  is  one  of  those  curious  bodies,  allied  to 
catalyse  and  oxidase,  that  Verworn  has  explained  so  luminously 
to  us,  and  that  Strauss  and  Winternitz  have  worked  with.  If 
so,  we  have  some  glimmerings  of  light  on  the  ultimate  mech- 
anism of  gas  production,  both  in  acapnia  and  in  flatulence. 
For  the  moment,  however,  it  is  to  the  fact  that,  in  degree,  in  all 
these  cases  there  seems  to  be  some  limitation  of  oxygenated 
blood-supply  that  I  ask  your  attention.  I  will  not  exclude 
even  the  purely  hysterical  cases,  in  which  there  is  evolved  gas, 
and  the  globus  hystericus. 

In  a  recent  admirable  lecture  by  Dr.  Campbell  Thomson, 
stress  is  laid  on  the  "  vasomotor  basis,"  if  I  may  use  the  term, 
of  neurasthenia  ;  and  on  the  dissociation  in  neurasthenia,  and 
also  in  hysteria,  of  what  I  may  call  "vasomotor  units."  Janet's 
dissociation  theory  of  hysteria  is,  of  course,  a  different  matter, 
though  physical  and  psychical  analogies  are  not  new.  And  this 
dissociation  notion  is  but  complementary  to  Sielig's  theory  of 
irradiation.  The  fact  is,  we  have  so  long  been  under  the  spell 
of  the  cerebro-spinal  neurologists  that  we  have  neglected  the 
55^1  pathetic.  The  idea  of  the  autonomic  nervous  system,  as 
set  forth  by  Professor  Sherrington,  may  redress  the  balance. 
Still,  what  we  have  to  remember  is  that  though  in  the  old- 
fashioned  cerebro-spinal  system  there  is  an  hierarchy,  in 
which  lower  centres  are  subordinated  to  upper  ones,  in  the 
sympathetic  we  have  a  different  arrangement,  reminiscent  of 
that  stage  in  the  history  of  the  race  in  which  there  is  segmenta- 
tion, or  a  series  of  units,  that  are  linked  together,  and  of 
which  none  is  subordinate  to  any  other.  But  the  efficient 
working  of  the  autonomic  system  depends  on  such  co-opera- 
tion between  the  two  elements  as  is  secured  at  the  synapses, 
subject  to  efficiency  of  the  supreme  head.  When  the  synapses 
are  disconnected,  as  they  certainly  are  by  nicotine,  the  various 
segments,  or  some  of  them,  rebel.  And  so  there  are  different 
"  types  "  of  neurasthenia — sexual,  intestinal,  gastric,  cardiac, 
and  so  forth.     But,  you  will  ask,  how  does  this  concern  those 


30  FLATULENCE 

cases  in  which  pneumatosis  is  a  consequence  of  shock,  of  emo- 
tion, or  of  acute  infectious  disorders  ?  The  autonomic  nervous 
system  gives  us  ahnk  between  skin  stimulation  and  visceral 
effect  (probably  in  great  part  a  matter  of  the  vasomotor  con- 
nections) that  obtains  equally  as  a  justification  for  the  use  of 
poultices  or  counter-irritation  in  visceral  disease,  and  as  an 
explanation  of  the  unhappy  consequences  of  a  winding  blow 
below  the  belt ;  while  at  the  same  time  it  explains  the  reverse 
effect,  of  visceral  disease  setting  up  superficial  skin  tenderness, 
and  the  extraordinarily  good  results  of  Franke's  operation 
(avulsion  of  the  intercostal  nerves  from  the  ganglia)  in  the 
gastric  crises  of  locomotor  ataxy.  The  nature  of  these  sensory, 
visceral,  and  vasomotor  connections  is  well  explained  in  a 
recent  paper  by  Watson  Wadsworth. 

Another  link  is  found  in  a  synthesis  of  the  work  of  Cannon, 
Hoskins,  Hemmeter,  Meltzer,  and  many  others,  who  have 
established  the  importance  of  the  adrenal  machinery  in  shock, 
in  emotional  stress,  and  in  acute  specific  disorders.  Their 
work  has  been  both  simphfied  and  obscured  by  our  realiza- 
tion that  the  adrenals  themselves  are  not  merely  a  pair  of 
organs  secreting  a  special  substance,  but  almost  an  integral 
part  of  the  sympathetic  system  at  any  rate  so  far  as  their 
medullary  substance  is  concerned.  Moreover,  there  is  the  as 
yet  only  half-suspected  importance  of  that  wonderful  series 
of  paired  organs  —  the  accessory  adrenals  or  chromaffine 
bodies,  coterminous  with  the  chain  of  sympathetic  gangha.  I 
say  only  half-suspected ;  for,  though  Sajous  long  ago  hinted 
at  the  function  of  adrenal  secretion  as  an  oxygen  carrier,  or, 
at  any  rate,  as  one  of  the  active  elements  in  the  management 
of  internal  respiration,  or  tissue  gas-exchange,  it  is  only  the 
other  day  that  Falta  and  Priestley  proved  that  the  chromaffine 
bodies  generally  are  active  agents  in  the  conduct  of  "  internal 
respiration,"  and  Fuchs  and  Roth  showed  how  injection  of 
adrenalin  increases  the  intake  of  air  and  the  output  of  carbonic 
acid  gas  by  the  lungs.  It  is  possible  that  we  may  find  oxidase 
or  catalyse  to  take  origin  in  these  structures.  Need  I  point 
out  to  you  that  these  chromaffine  bodies  are  very  perfectly 
provided  in  those  fishes  that  have  swimming-bladders  ?  or 
allude  to  the  breathlessness,  the  air  hunger,  and  the  notable 
flatulence  of  patients  with  Addison's  disease,  that  you  may 
agree  that  the  hypothesis  of  gas  secretion  from  the  stomach 
is  not  foolish,  and  that  Trousseau  and  Graves,  our  veterinary 


FLATULENCE  31 

surgeon  at  Lanark,  and  acute  practitioners  like  Dr.  Muir  Evans, 
may  now  stand  in  line  with  the  most  eager  workers  in  Conti- 
nental and  transatlantic  laboratories  ? 

There  is  a  maze  of  splanchnic  effects  and  of  sympathetic 
effects  ;  of  tonus,  hypotonus,  and  hypertonus  ;  of  stimulations 
and  depressions  ;  of  inhibitions  and  of  activations  ;  of  oxida- 
tions and  of  oxidation  arrests  ;  of  reflexes  this  way  and  that ; 
of  paralyses  and  spasms  ;  of  checks  and  counter-checks  to  be 
explained.  Most  puzzling  of  all  are  the  diverse  effects  of 
adrenalin  itself.  At  one  time  we  find  it  necessary  to  the  main- 
tenance of  muscular  tonus  ;  at  another,  that  an  excessive  dose 
is  destructive  of  tone.  There  is  the  suggestion  of  purely  local 
action  or  selection,  and  there  is  Cannon's  idea  of  sensitive 
spots  ;  but  perhaps  the  nearest  approach  to  a  solution  has 
been  given  by  Hoskins. 

The  exact  elucidation  of  the  connection  that  undoubtedly 
does  obtain  in  the  various  cases  of  pneumatosis  between  the 
arteries,  the  nervous  mechanisms,  and  the  chromaffine  organs, 
is  not  yet  for  us.  That  there  is  such  a  connection,  and  that 
when  we  have  it  explained  we  shall  understand  both  the  gas 
production  and  the  eccentricities  of  muscular  and  arterial  tonus 
that  are  common  to  them  all,  I  am  convinced. 

No  doubt  the  chain,  or  vicious  circle,  composed  of  vascular, 
nervous,  and  chromaffine  systems,  may  be  commenced  or 
broken  at  any  point.  In  purely  hysterical  cases  the  deter- 
mining influence  is  from  above.  In  shock  cases,  in  ileus,  and 
in  those  arising  during  diphtheria  and  other  disorders,  the 
adrenal  or  chromaffine  system  is  exhausted  ;  and  so  it  is  in 
these  that,  as  we  should  expect,  the  gas  secretion  is  most 
abundant,  the  internal  respiration  most  affected,  the  acapnia 
most  obvious,  and  death  least  rare. 

In  neurasthenia  and  in  the  anginal  conditions,  true  and 
false,  the  effects  are,  as  a  rule,  dependent  on  one  or  two  of  the 
vasomotor  "  segments  "  controlled  by  the  autonomic  system. 
In  primary  vaso- vagal  cases,  probably  in  the  basal  pneumonias, 
and  certainly  in  many  of  the  dyspeptics,  irritation  of  afferent 
vagal  fibres  seems  to  start  the  ball  rolling.  So  that  the  relation 
of  duodenal  ulcer  to  flatulence  is  twofold.  When,  as  in  shock 
from  burns,  and  perhaps  in  other  cases,  acute  mucous  ulcer 
and  flatulence  develop,  we  have  an  intensive  use  of  the 
mechanism  that  is  employed  when  we  put  a  mustard  plaster 
or  poultice  on  the  skin  by  way  of  counter-irritation.     When 


32  FLATULENCE 

a  chronic  ulcer  of  the  duodenum  or  irritative  ingesta  set  up 
flatulent  attacks  with  irradiating  and  anginal  S37mptoms,  the 
"  viscero- vasomotor  "  mechanism  is  primarily  engaged.  But 
in  each  case  all  three  elements  are  involved,  and  we  should  not 
forget  what  Crile  has  called  the  "  master  key  " — racial  habit, 
or  phylogenetic  association.  We  may  surmise  that,  just  as 
the  Teleostean  fish,  when  it  sinks  to  escape  its  enemies,  adjusts 
its  swimming-bladder  and  gains  a  different  sea-level,  so  do  we, 
when  brought  low  by  stress  or  exhaustion,  unconsciously 
protect  ourselves,  or  component  segments  from  aggression,  by 
the  evolution  of  gases.  Shock  itself  is  protective ;  and,  in 
fact,  it  is  not  easy  to  think  of  a  single  manifestation  in  either 
hysteria  or  neurasthenia  which  is  not  more  or  less  defensive. 

Perhaps  hysteria  is  rather  defensive  against  injury  to  per- 
sonal interests,  whilst  neurasthenic  manifestations  are  protec- 
tive to  physical  stresses.  That  is  to  say,  in  the  latter  case  the 
organs  threatened  with  damage  from  abuse  are  thrown  out 
of  gear  by  segmental  dissociation.  And,  just  so,  if  an  hys- 
terical woman  is  called  on  to  make  some  self-sacrifice,  she 
finds  her  defence  in  dislocating  the  mechanism  that  should  be 
employed  in  the  ungrateful  task. 

The  treatment  of  these  various  flatulencies  is  not  always 
easy,  but  a  few  practical  hints  may  be  given. 

It  is  clear  that,  when  microbic  fermentation  is  the  pre- 
dominant element  in  gas  production,  washings  out,  antiseptics, 
acids  and  pepsin,  and  a  diet  suitable  to  the  occasion,  are 
obviously  to  be  prescribed. 

In  the  great  "  dietetic  "  or  "  coction  "  group,  one  may  have 
greater  difficulty  in  finding  what  to  order  or  what  habit  to 
correct ;  but  alkaHes  after  meals  will  help  most. 

In  the  complex  group  of  flatulencies  from  "  secreted  "  gas 
these  measures  will  hardly  serve.  It  is  obvious  that  an  etio- 
logical, or  rather  a  pathological,  diagnosis  is  required.  By 
way  of  immediate  treatment :  remember  Trousseau's  "  cold 
affusions  and  ether."  Prescribe  local  vaso-dilators,  rube- 
facients, anti-spasm odics.     "  Dry"  meals  are  best. 

But,  in  strictest  confidence,  I  will  tell  you  this  :  should 
any  of  you,  from  overwork,  overmuch  tea,  overmuch  tobacco, 
or  what  not,  get  a  spell  of  neurotic  flatulence,  and  eructations 
with  air  gulping,  nothing  will  give  you  so  much  relief  as  a  bottle 
of  the  very  best  creme  de  menthe,  sipped  slowly  and  steadily 
until  you  are  better. 


SHOCK* 

The  discussion  and  understanding  of  shock,  although  of  para- 
mount importance  to  the  clinician,  the  physiologist,  and  the 
lawyer,  is  involved  in  much  obscurity.  Perhaps  it  would  be 
well  to  avoid,  at  any  rate,  terminological  confusion  by  setting 
on  one  side,  as  distinct  from  shock,  the  condition  known  as 
"  collapse."  By  "  collapse  "  we  mean  that  sum  of  bodily 
states  which  is  associated  with  loss  or  draining  of  the  vital 
fluids,  as  in  haemorrhage  or  cholera.  Shock  remains  as  the 
sum  of  conditions  obtaining  when  the  reaction  by  the 
nervous  systems  to  afferent  impulses  is  incompatible  with  the 
usual  performance  of  vital  functions,  so  that  the  patient  may 
die  without  the  necessary  coincidence  of  any  obvious  lesion 
in  itself  inconsistent  with  life.  But,  of  course,  shock  and 
collapse  may  coexist. 

We  cannot  hope  to  estimate  the  intensity  of  the  afferent 
impulses  that  is  requisite  to  destroy  life  by  shock  ;  for,  as  Mr. 
Tyrrell  Gray  has  said,  we  have  to  reckon  with  the  shock  value 
of  the  individual.  Probably  this  shock  value  is  a  physiological 
"  function,"  but  there  are  racial  values  as  well  as  individual 
values.  In  great  measure  these  depend  on  the  state  of  the 
internal  secretions  or  their  balance.  Thus,  the  hyperthyroidal 
Bengalee  has  a  higher  shock  value  than  the  negro,  and  the 
lively  Gaul  is  more  easily  perturbed  than  the  phlegmatic 
Teuton. 

Still,  the  shock  value  of  an  individual  varies  from  time  to 
time,  and  different  parts  of  the  body  have  different  shock 
values.  A  tap  below  the  belt  may  wind  a  man  on  whose 
thorax  I  could  hammer  without  causing  distress ;  and  there 
are  other  elements — to  wit,  that  of  unpreparedness.  A  false 
step  in  the  dark  may  momentarily  shake  the  nerves  of  a  man 
who  will  take  the  spills  of  a  day's  hunting  without  turning  a 

*  A  paper  read  before  the  Medico-Legal  Society,  October  22,  1912. 

33  3 


34  SHOCK 

hair ;  and  the  late  Mr.  Dent  pointed  out  how  a  policeman, 
suddenly  injured  when  on  duty  in  a  street  brawl,  will  suffer 
more  severely  from  shock  than  a  soldier  wounded  in  action. 

Again,  the  trauma  may  be  what  is  called  "  psychical,"  as 
when  a  piece  of  bad  news  is  communicated,  or  there  is  a  sudden 
and  terrifpng  sight ;  although  there  is  always  a  physical 
process  underlying  psychical  impression. 

When  these  factors  are  considered,  it  must  be  agreed  that, 
unless  there  be  definite  simulation,  we  have  little  justification 
for  aspersing  one  who  complains  of  serious  perturbations  on 
an  occasion  that  may  seem  to  us  trivial.  Many  people  have, 
indeed,  as  we  say,  died  of  simple  fright. 
f  I  spoke  just  now  of  the  nervous  systems  designedly  ;  for  we 
have  not  one,  but  three,  nervous  systems.  We  have  the 
'  cerebro-spinal  nervous  system,  the  S5mipathetic  nervous 
system,  and  also  the  co-ordination  of  parts  of  these  two  into 
a  third  organization — the  autonomic  nervous  system.  If,  for 
the  sake  of  legal  members,  I  may  hazard  an  illustration,  I 
would  say  that  just  so  in  this  country  we  have  a  fairly  stable 
and  organized  aristocracy  and  a  less  coherent  democracy  ; 
though  the  system  on  which  the  stability  of  the  constitution 
depends  is  that  formed  by  the  co-operation  of  a  part  of  the 
aristocracy  and  a  part  of  the  commonality.  And,  seemingly, 
in  shock  the  maintenance  of  the  functional  iirEegnty  of  the" 
autonomic  jystem  is  seriously  compromised.  It  is  certainly 
true  that  what  doctors  call  "  shock  "  (meaning  thereby  the 
consequences  of  a  shock)  is,  in  part,  a  defensive  reaction  of 
the  autonomic  nervous  system  against  assault  that  has  been 
committed. 

It  fails  of  its  purpose  at  times,  no  doubt,  and  may  even  be 
too  intense  for  the  safety  of  the  organism.  But  the  fact 
remains  that,  as  Crile  has  pointed  out,  the  shock  mechanism 
is  one  forged  many  generations  c^go  in  the  history  of  the  race, 
when  some  apparatus  was  necessary  to  secure  instant  prepara- 
tion for  flight  or  withdrawal  on  occasion  of  danger. 

Poke  a  snail  with  a  straw,  and  see  it  draw  in  its  horns. 

Such  are  the  beginnings  of  the  complexes  of  shock  and  of 
traumatic  neurasthenia  which  so  admirably  contribute  to  the 
support  of  our  twin  professions.  But  just  as  a  rifle  may  have 
too  light  a  pull,  so  may  the  shock  reaction  be  overdone,  to 
the  disadvantage  of  the  organism. 

It  is  perhaps  somewhat  unfortunate  that,  owing  to  the 


SHOCK  35 

possibly  excessive  attention  paid  to  experimental  work  of  late 
years,  shock,  to  the  minds  of  many  medical  men,  has  come  to 
mean  an  affair  of  blood- pressure  curves,  and  what  not,  that 
can  be  best  investigated  in  dogs  and  on  rabbits.  And  so  some 
of  the  shock  effects  that  can  hardly  be  investigated  save  by 
observations  on  human  beings  have  become  a  little  dis- 
credited, and  are  almost  treated  as  if  they  had  no  existence, 
or,  at  any  rate,  no  right  to  be  mentioned  in  polite  professional 
society.  It  is  to  some  of  these  shock  effects,  and  particularly 
to  those  indicated  by  the  term  "  delayed  shock,"  once  in  some 
clinical  favour  but  now  a  little  in  the  shade,  that  I  propose 
to  refer. 

If  we  have  to  state  the  most  intense  form  of  shock,  we  at 
once  think  of  those  cases  of  sudden  death,  where  there  is  no 
precedent  disease,  that  are  brought  about  by  events  which 
produce  no  obvious  lesion.  Such  deaths  happen  when  there 
is  sudden  immersion  in  water,  and  the  individual  dies  without 
having  time  to  drown.  Other  examples  are  narrated  by 
Brouardel  in  his  book,  wherein  he,  following  Brown-Sequard, 
speaks  of  them  as  deaths  from  inhibition.  Let  me  give  you 
an  instance. 

Last  summer  a  Sikh  was  cycling  through  a  London  street. 
He  had  a  side-sHp  when  opposite  a  hospital.  He  was  at  once 
taken  in,  but  no  injury  was  found  save  a  dislocated  thumb, 
which  was  reduced.  He  turned  to  leave  the  hospital,  and 
died  on  the  doorstep.  At  the  post-mortem  neither  injury  nor 
disease  was  found. 

When,  however,  shock  falls  short  of  immediate  death  pro- 
duction, there  may  be  a  very  serious  condition  lasting  some 
twenty-four  hours  or  so,  which  may  be  terminated  by  death 
or  may  end  in  gradual  recovery.  This  is  the  common  kind  of 
shock,  from  which  we  say  people  suffer  after  operation  or 
serious  injury. 

But  there  is  a  group  of  serious  cases  in  which,  after  the 
infliction  of  some  traimia,  the  subject  displays  emotional 
perturbation,  rallies,  seems  to  be  doing  well,  and  yet  ultimately 
develops  symptoms  which  may  be  indifferently  severe  or  may 
terminate  in  death. 

The  cases  from  which  there  is  recovery  sometimes  pass  as 
"  traimiatic  neurasthenia,"  in  which,  as  all  know,  a  definite 
latent  period  elapses  between  the  symptoms  immediately  dis- 
played and  those  that  "  come  on  "  later,  and  give  us  so  much 


36  SHOCK 

occasion  for  professional  activity.  The  cases  in  which,  after 
a  latent  period  that  may  be  long  or  short,  grave  and  even 
fatal  consequences  ensue,  are  those  to  which  I  now  refer  as 
cases  of  "delayed  shock,"  using  a  term  that  is,  or  was, 
consecrated  by  use. 

Common  to  both  traumatic  neurasthenia  and  delayed  shock 
are  unexpectedness  of  the  trauma,  and  high  psychical,  rather 
than  physical,  value  of  the  causative  incident. 

The  prolonged  anxiety  and  stress  of  shipwreck  is  not  so 
effective  in  producing  traumatic  neurasthenia  or  delayed 
shock  as  is  a  railway  collision,  or  a  prank  played  on  a  kitchen- 
maid  with  a  turnip,  a  clothes-prop,  and  a  candle. 

Now,  it  is  not  an  unreasonable  deduction  that  the  symptoms 
which  follow  the  latent  interval  are  perhaps  due  to  the  exhaus- 
tion of  certain  mechanisms  in  combating  the  immediate 
effects  of  the  physical  or  psychical  trauma.  And,  indeed, 
years  ago  Mr.  Fumeaux  Jordan  very  acutely  pointed  out 
that  many  of  the  immediate  manifestations  of  what  we  call 
"  shock  "  are  really  efforts  of  the  organism  to  combat  the 
effect  of  the  trauma. 
/  When  we  have  a  sudden  fright,  if  taken  off  our  guard,  we 
turn  pale.  The  blood  is  diverted  from  the  skin,  where  it  is 
not  needed,  to  the  heart  and  lungs,  so  that  these  organs  are 
well  supplied  for  the  immediate  flight  prompted  by  our 
ancestral  origins. 
\/  Now,  the  experimental  work  of  Cannon  and  his  associates 
seems  to  prove  that  when  animals  have  been  subjected  to 
injury,  or  deliberately  frightened  to  death,  the  adrenal  system 
(a  part  of  the  mechanism  that  manages  the  blood-distribution) 
may  be  so  completely  exhausted  by  its  efforts  that  it  becomes 
bankrupt,  and  death  ensues. 

In  these  experiments  we  seem  to  see  the  physiological 
explanation  of  the  phenomena  of  "  delayed  shock"  in  human 
beings. 

Cases  of  delayed  shock  are  not  very  uncommon,  but  they 
are  often  masked.  We  all  know  how  usual  it  is  for  an  aged 
person  to  die  a  week  or  two  after  a  slight  fall  that  has  involved 
fracture  of  the  femur.  This  is  "  delayed  shock."  It  escapes 
recognition  as  such  only  because  there  is,  what  sounds  for- 
midable, a  fracture  of  the  thigh. 

Yet  a  fracture  of  the  thigh  is  itself  a  trivial  affair  so  far  as 
life  is  concerned.     It  is  true  that  sometimes  a  low  kind  of 


SHOCK  37 

pneumonia  ensues,  but  not  always  ;  and  even  when  it  does, 
there  is  a  valid  explanation.  At  any  rate,  the  pneumonia 
itself  is  seldom  so  severe  as  necessarily  to  interfere  with  life. 
Again,  after  burns,  death  from  delayed  shock  is  not  infrequent 
even  when  no  vital  organ  has  been  implicated  and  there  is 
little  sepsis. 

The  point  that  I  am  anxious  to  establish  is  this  :  that  when 
death  occurs  ten  days  or  so  after  trauma,  we  should  not  hesi- 
tate to  ascribe  death  to  the  "  accident  "  merely  because  there 
has  not  been  present  such  a  totally  irrelevant  lesion  as  a  frac- 
ture of  the  thigh  or  an  extensive  scald. 

I  do  not  say  that  such  deaths  are  very  common,  for  obviously 
there  usually  is  a  lesion  ;  but  they  do  occur.  I  have  met  with 
several,  and  have  had  the  opportunity  of  inquiring  into  others. 
Many  have  been  recorded  in  forgotten  papers  ;  but  the  modern 
textbooks  ignore  them  in  most  remarkable  fashion,  and  even 
so  erudite  a  compilation  as  Mr.  Knocker's  makes  no  mention 
of  their  happening. 

Though  they  present,  as  is  only  natural,  points  of  individual 
difference,  there  are  not  a  few  S5miptoms  from  which  we  can 
construct  a  common  denominator. 

There  is  usually  immediate  manifestation  of  some  psychical 
agitation  ;  but  this  may  pass  off.  There  is  a  longer  or  shorter 
period  in  which  the  patient  may  seem  to  be  suffering  hardly  at 
all ;  and  there  are  indications  of  interference  with  the  visceral 
functions.  The  blood-pressure  is  affected,  and  the  heart  tends 
to  dilate,  for  it  loses  tone  ;  the  urine  is  scanty ;  the  bowels 
are  obstinately  constipated  ;  flatulence  and  eructations  are 
common  ;  and  there  is  a  good  deal  of  shortness  of  breath.  As 
it  may  be  the  respiratory,  the  cardiac,  the  gastric,  the  intes- 
tinal, or  other  symptoms,  that  notably  attract  the  doctor's 
attention,  so,  if  death  occurs,  it  is  ascribed  to  congestion  of 
the  lungs,  to  heart  failure,  to  pressure  of  the  stomach  on 
the  heart,  to  stoppage  of  the  bowels,  or  even  to  suppres- 
sion of  urine.*  Sometimes  the  flatulence,  constipation, 
and  distension  are  so  marked  that  operation  is  proposed  and 
carried  out ;  but  no  condition  is  found  within  the  surgeon's 
ambit. 

When  after  trauma  there  are  continuing  hysterics,   the 

*  In  a  measure,  the  "  shock  mechanism  "  may  be  concerned  in  some 
"obstructive"  suppressions  of  urine.  The  relation  of  Grave's  disease 
to  shock  should  not  be  forgotten. 


38  SHOCK 

patient  will  probably  win  through  with  little  physical  damage. 
When  the  early  psychical  disturbances  have  play,  but  are 
controlled,  traumatic  neurasthenia,  or  the  more  marked  type 
of  "  delayed  shock,"  may  ensue.  But  sometimes  there  is  no 
initial  hysteria ;  the  subject  displays  a  peculiar  apathy,  and 
death  is  pretty  sure  to  follow. 
You  will  aU  remember  how  when — 

"  Home  they  brought  her  waxrior  dead  ; 
She  ne'er  spoke  nor  uttered  cry  ; 
All  the  maidens  watching  said  : 
'  She  must  weep,  or  she  will  die.'  " 

In  such  cases  the  autonomic  nervous  system  is  thoroughly 
disorganized,  probably  by  inhibition  from  above. 

The  connections  at  the  synapses  are  broken,  and  unless 
contact  is  re-estabUshed  death  may  ensue. 

The  warrior's  lady  had  her  fount  of  tears  dried  up,  and 
probably  she  was  obstinately  constipated  and  passed  no 
water ;  when  her  autonomic  nervous  system  got  to  work 
again  not  only  the  tears  but  other  secretions  were  doubtless 
abundantly  established,  with  excellent  results. 

Mr.  Clinton  Dent  once  related  how  many  years  ago  at 
St.  George's  Hospital  a  water-tank  burst  through  a  ceiling 
and  the  floor  below,  carrjring  with  it  in  its  career  a  bed  in 
which  was  a  woman  convalescent  from  some  unimportant 
affection.  This  woman,  in  spite  of  her  precipitate  descent  to 
the  lower  ward,  sustained  no  overt  injury  save  a  trifling  scalp 
wound.  But  she  passed  into  a  curiously  apathetic  condition, 
like  that  exhibited  by  some  patients  who  have  been  burnt. 
She  was  seen  by  the  late  Mr.  Caesar  Hawkins,  who  said  that, 
though  he  could  give  no  reason  for  his  opinion,  yet  his  experi- 
ence taught  him  that  she  would  die.  She  did  die,  about  three 
weeks  after  the  accident,  and  at  the  post-mortem  no  lesion 
was  discovered.  Mr.  Page  recorded  the  case  of  a  girl  who 
was  shaken  in  a  railway  accident.  She  was  hysterical  at  the 
time,  but  rallied,  then  took  to  her  bed,  and  died,  without  any 
obvious  reason,  in  about  five  weeks.  Sir  Samuel  Wilks  has 
narrated  other  cases  of  the  same  sort, 

Mr.  Turner  several  years  ago  reported  the  case  of  a  man 
who  fell  when  crossing  a  railway  track  and  broke  his  leg. 
That  same  night  he  developed  retention  of  urine,  absolute 
constipation,  and  abdominal  distension.  In  two  days  he  was 
lying  in  bed  "like  a  ball."    He  had  no  peritonitis  or  other 


SHOCK  39 

indication  of  visceral  injury.  But  he  died  on  the  tenth  day. 
It  is  true  that  before  he  died  some  pneumonia  developed,  but, 
as  Mr.  Turner  says  in  a  pregnant  phrase,  this  shows  that  the 
shock  had  affected  other  organs  than  the  bowels. 

Cases  of  what  is  called  "  traumatic  pneumonia  "  are  not  very 
uncommon,  and  one — the  case  of  Etherington — is  a  legal  classic. 

But  the  usual  explanation  given  is  that  the  accident  or 
injury  in  some  mysterious  way  lowers  the  patient's  vitality, 
and  renders  him  or  her  more  susceptible  to  the  pathogenic 
growth  in  the  lungs  of  the  pneumococcus,  which  is,  of  course, 
a  very  usual  denizen  of  the  mouth.  This  mysterious  lowering 
of  vitahty  seems  to  me  a  phrase  which  explains  nothing. 

It  has  some  appearance  of  plausibiHty  when  the  pneumonia 
follows  a  blow  on  the  chest,  but  it  loses  force  when  we  consider 
the  case  of  a  man  with  a  broken  leg  ;  so  that  it  is  then  usual 
to  suggest  that  the  pneumonia  is  hypostatic,  the  result  of 
congestion  of  the  lung  from  confinement  to  bed.  Mr.  Turner's 
case  forces  us  to  seek  some  other  explanation,  and  his  expres- 
sion, that  the  pneumonia  showed  that  the  shock  had  affected 
other  organs  than  the  bowels,  carries  us  some  way  towards  an 
understanding. 

Everyone  knows  that,  in  spite  of  the  jeers  of  therapeutic 
nihilists,  a  poultice  or  a  mustard-plaster  applied  to  the  skin 
does  affect  the  functional  state  of  deep-seated  organs.  And 
we  know  that  disease  processes  in  certain  organs  give  rise  to 
pain  in  correlated  skin  areas.  Now,  whereas  till  lately  the 
notion  of  what  is  called  "  counter-irritation  "  had  been  a  little 
discredited,  the  phenomenon,  for  instance,  of  abdominal  pain 
and  tenderness  in  pneumonia  does  show  us  that  there  is 
an  active  connection  between  the  cutaneous  nerves  and  the 
viscera,  and  no  longer  renders  it  foolish  to  think  that  an  active 
poulticing  may,  through  the  nerves  controlling  the  distribution 
of  blood  to  an  organ,  so  affect  the  vascular  state  of  that  organ 
as  to  favourably  influence  disease  processes. 

And  we  have  physiological  justification  for  assuming  or 
believing  that,  let  us  say,  the  application  of  cold  to  the  skin 
may,  under  certain  circumstances,  so  affect  the  state  of  deep 
viscera,  in  respect  of  the  local  circulation  of  blood  therein, 
as  to  pave  the  way  for  the  establishment  of  an  active  microbic 
inflammation. 

We  know,  too,  that  normally  certain  skin  areas  are  corre- 


40  SHOCK 

lated  with  certain  viscera  for  good  or  for  evil.  But  we  have 
to  reckon  with  the  phenomenon  of  irradiation,  whereby  the 
effects  of  an  intense  nerve  impression  spread  to  units  of  the 
autonomic  nervous  system  (which  is,  indeed,  a  series  of  seg- 
ments or  units)  other  than  the  proper  one.  You  may  in  some 
buildings  see  a  telephone  switchboard  so  arranged  that 
different  persons  can  be  called,  or  can  call,  independently. 
Such  is  the  normal  arrangement  of  the  autonomic  system, 
whereby  skin  areas  can  call  up  visceral  areas,  and  vice  versa. 
But  an  arrangement  may  be  made  so  that  if  a  call  of  fire  is 
received  at  the  office  a  special  switch  can  be  thrown  over, 
and  the  various  instruments  can  be  simultaneously  rung. 
If  the  operator  is  a  fool,  this  is  done  unnecessarily. 

And  in  shock  something  of  this  sort  seems  to  occur ;  so 
that  we  can  see  how  it  is  that,  as  in  Mr.  Turner's  case  and 
others,  a  physical  and  psychical  trauma  may,  given  certain 
conditions,  adversely  affect  the  vascular  state  not  only  of 
the  bowels,  but  the  lungs.  Neuhof,  an  American  physician, 
has  lately  paid  particular  attention  to  this  mechanism  for  the 
occasional  production  of  pneumonia.  He  calls  some  such  cases 
of  pneumonia  "  vagus  pneumonias,"  for  physiological  reasons. 

A  case  of  great  legal  and  medical  importance  came  under 
my  notice  a  few  months  ago.  The  subject  was  a  man  well 
known  to  me  by  repute — healthy,  sober,  and  active.  His  age 
was  forty-nine.  On  the  evening  of  November  14  last  he 
left  the  house  of  a  friend  to  walk  to  the  station.  In  passing 
through  the  grounds  he  missed  his  way,  and  stepped  suddenly 
over  the  perpendicular  bank  of  a  brook,  or  ha-ha,  into  the 
water  below.  The  height  of  the  bank  above  the  water  was 
4  feet :  the  depth  of  the  water  about  2  feet  6  inches.  He  fell 
on  to  one  knee,  but  was  not  immersed,  so  scrambled  out  and 
made  his  way  back  to  the  house  in  a  state  of  some  agitation. 
He  was,  in  fact,  at  first  hysterical.  However,  he  got  home, 
a  distance  of  some  miles,  in  a  cab,  and  was  seen  by  a  doctor, 
who  found  no  injury  save  a  grazed  knee.  The  next  day 
the  unfortunate  gentleman  went  to  his  office  as  usual,  but 
complained  of  shortness  of  breath  and  some  pain  in  the  loins. 
The  hysteria  had  been  controlled. 

He  began  to  suffer  from  what  seemed  to  be  flatulent  dys- 
pepsia ;  the  wind  was  indeed  incessant ;  he  was  obstinately 
constipated,  and  passed  little  water.  He  became  worse,  yet 
attended  intermittently    to    business.      On    November    30, 


SHOCK  41 

sixteen  days  after  the  accident,  he  died  suddenly  after  drinking 
a  glass  of  water  to  relieve  his  "  wind." 

A  claim  was  made  on  a  company  in  which  he  was  insured 
on  the  ground  that  death  had  resulted  from  the  accident. 

A  post-mortem  examination  was  ordered  :  no  sign  of  any 
injury  or  surgical  condition  such  as  embolism  was  found. 
But  there  was  recent  dilatation  of  the  stomach  and  some 
dilatation  of  the  heart.  Owing,  however,  to  the  undoubted 
fact  that  decomposition  had  advanced  with  extreme  rapidity 
in  a  few  hours,  it  was  not,  in  the  opinion  of  some  who  were 
present,  possible  to  be  definite  as  to  the  non-existence  of  fatty 
degeneration. 

Therefore,  the  claim  was  disputed :  apparently  on  the  ground 
that  the  deceased  died  from  heart  failure,  possibly  in  some 
measure  due  to  a  hypothetical  precedent  degeneration,  but 
certainly  in  the  last  resort  determined  by  the  "  flatulent  dys- 
pepsia," if  not  by  the  drink  of  cold  water.  It  was  also  sug- 
gested that  the  flatulent  dyspepsia  was,  together  with  the 
constipation,  set  up  by  lack  of  exercise,  consequent  on  the 
slight  knee  injury  and  the  rest  at  home. 

In  fine,  death  was  not  due  to  the  accident. 

At  this  stage  my  opinion  was  asked  by  the  solicitor  for  the 
widow,  and  I  gave  it  to  the  effect  that  if  there  had  been  no 
accident  the  fatal  event  would  not  have  occurred — that, 
indeed,  the  case  was  one  of  delayed  shock. 

Learned  counsel  was  then  good  enough  to  read  me  the  case 
of  Etherington,  as  illustrating  the  legal  point  that  we  might 
have  to  meet. 

This  case  is  one  of  a  gentleman  who  had  a  fall  in  the  hunting- 
field,  went  up  to  town  the  next  day,  fell  ill,  and  presently 
died  of  pneumonia.  It  was  claimed  that  the  pneumonia  de- 
veloped as  a  result  of  the  vitality  having  been  lowered  by  the 
shock  of  the  fall,  pneumococci  being  present  in  the  body  at 
the  time.  The  claim  was  disputed  on  the  ground  that  the 
terms  of  the  policy  denied  benefits  if  there  should  be  inter- 
vening causes  between  accident  and  death,  and  it  was  asserted 
that  the  pneumonia  was  such  an  intervening  cause.  On 
appeal,  the  Lords  Justices  held  that  the  insurance  company 
were  not  entitled  to  relief  if  the  intervening  incident  or  cause 
were  a  link  in  the  natural  chain  of  events  or  causes  developed 
between  the  accident  and  the  death,  inasmuch  as  the  words 
of  the  policy  were  to  be  construed  as  applying  only  to  the 


42  SHOCK 

fortuitous  intervention  of  some  other  or  fresh  agency  causing 
death.  They  held  that  the  pneumonia  was  no  such  fortuitous 
intervention,  but  an  incident  in  the  natural  chain  of  events, 
and  gave  judgment  against  the  company.  In  our  case  I 
certainly  thought  that  there  was  not  the  intervention  of  any 
fresh  agency,  and  so  we  went  to  arbitration.  But,  after 
the  hearing  of  \\dtnesses  as  to  fact,  an  offer  of  compromise 
was  made  and  accepted,  so  that  the  question  of  delayed 
shock  was  never  submitted  to  the  learned  arbitrator, 

I  think  you  will  agree  with  me  that  it  is  important  that  the 
exact  nature  of  cases  such  as  these  should  be  defined.  In  the 
case  of  Etherington  there  was  a  definite  intervening  illness, 
indicated  at  the  post-mortem  by  the  usual  signs.  Superficially 
it  might  seem  that  here  the  insurance  company  had  a  good 
case.  But.  apart  from  the  luminous  interpretation  of  the 
words  of  the  particular  pohcy  bj^  Lord  Justice  Williams, 
medically  they  had  a  bad  one.  Only  the  medical  witnesses 
for  the  claimants  might  have  put  their  case  a  little  higher — 
"  precised  it."  as  the  French  say — and,  instead  of  speaking 
generally  of  lowered  vitality,  drawn  attention  to  the  definite 
mechanism  that  exists  in  the  autonomic  nervous  system  for 
the  production,  in  shock,  of  disturbance  of  function  in  special 
viscera.  In  my  case,  however,  there  was  no  gross  or  organic 
condition  such  as  pneumonia  to  set  up  as  an  intervening 
agency  ;  there  was  really  no  disease  at  all  discoverable  at  the 
post-mortem,  and  until  the  time  of  death  there  had  been 
no  symptoms  that  required  the  assumption  of  what  we  call 
"  organic  change  "  to  render  them  comprehensible.  It  was 
apparently  because  there  was  no  more  than  functional  disorder 
manifested  that  the  insurance  company  hesitated  to  meet  the 
claim.  If  there  had  been  the  fracture  of  even  one  bone,  had 
there  been  a  patch  of  pneumonia  no  bigger  than  a  crown-piece 
that  we  could  have  sworn  to,  all  would  have  been  well.  But 
neither  the  discovery  of  a  fracture  nor  the  existence  of  a 
pneimionia  would  have  really  made  the  case  any  stronger. 
And,  after  all,  the  man  was  dead.  A  healthy,  sober  man,  who 
had  never  before  spent  a  day  in  bed,  died  sixteen  days  after 
the  accident  while  under  treatment  for  flatulence  and  constipa- 
tion. He  died  of  "  delayed  shock,"  as  it  is  called,  truly  and 
Tmquestionably,  as  did  the  persons  whose  cases  I  have  already 
narrated,  and  as  every  day  do  people  die  who  have  broken  a 
femur,  or  have  been  burnt,  or  suffer  from  post-operative  ileus. 


SHOCK  43 

It  is  not  necessary  to  labour  the  point  that  in  this,  as  in 
other  cases,  the  trauma  was  unexpected.  But  it  links  these 
fatal  cases  with  the  non-fatal  ones,  in  which,  equally,  there 
is  no  symptom  that  may  not  be  referred  to  functional 
derangement  —  namely,  those  of  traumatic  neurasthenia, 
wherein  also  it  is  clear  that  the  protective  mechanism  of 
the  body  is  taken  "  off-side."  There  is  no  time  for  pre- 
paratory adjustment  of  the  blood-distribution  in  the  body 
to  the  purpose.  And  it  is  then  easy  to  understand  how,  given 
a  high  shock  value,  under  such  circumstances  the  protective 
adaptation  may  be  out  of  all  proportion  to  the  occasion,  as 
when  the  telephone  operator  is  excited  by  a  rimiour  of  fire. 

What  the  exact  significance  of  the  latent  interval  is,  it  is 
difficult  to  say,  but  it  must  be  observed  how  generally  there 
is  some  flatulence,  which  in  slighter  cases  may  pass  as  due  to 
dyspepsia,  and  in  the  more  grave  may  lead  to  such  distension 
that  the  surgeon's  aid  is  invoked. 

Now  this  flatulence  is  not  dyspeptic.  It  has,  it  is  true,  an 
intimate  relation  to  the  flatulence  of  what  is  called  "  neurotic 
dyspepsia,"  but,  as  I  have  tried  to  show  elsewhere,  this 
flatulence  too  is  an  affair  of  actual  gas  secretion  from  the 
stomach  and  bowels,  and  brings  the  shock  cases  we  have  been 
discussing  into  line  with  those  of  acapnia,  to  which  so  much 
attention  has  been  directed  by  Professor  Henderson  of  Yale, 
and  Dr.  Crile. 

Now,  in  all  these  curious  cases  in  which  gas  secretion  occurs 
three  systems  are  involved — the  vasomotor,  the  autonomic 
nervous,  and  the  adrenal. 

The  direct  connection  between  the  adrenal  system  and  the 
production  of  gas  in  shock  and  in  acapnia  has,  I  think,  had 
light  thrown  on  it  recently  by  Falta  and  by  Fuchs,  who  have 
shown  that  the  adrenal  system  not  only  provides,  as  we 
know,  a  substance  that  influences  the  tone  of  the  bloodvessels, 
heart,  stomach,  bowels,  and  other  organs,  but  a  substance  or 
substances  that  seemingly  control  the  internal  respiration — 
the  exchange  of  gases  between  the  tissues  and  the  blood.  If, 
then.  Cannon  is  right  in  holding  the  adrenal  or  chromaffine 
system  responsible  for  the  adjustment  of  the  body  in  cases  of 
shock,  we  can  understand  how  it  is  that  the  sjmiptom  of 
flatulence,  though  present  in  varying  degree,  is  a  thread  link- 
ing many  of  these  conditions  together. 

Whether  this  gas  secretion  is  indicative  of  exhaustion  of 


44  SHOCK 

the  adrenal  system,  or  whether  it  marks  the  excessive  activity 
that  heralds  exhaustion,  or  whether  it  is  sometimes  or  always 
an  expression  of  perversion,  rather  than  of  excess  or  deficiency, 
it  is  hard  to  say.  On  the  answer  to  these  questions  depends 
probably  determination  of  the  treatment  that  we  should 
prescribe. 

It  is  not  my  desire  to  pursue  here  the  purely  medical  aspects 
of  these  questions  ;  I  have  done  that  elsewhere.  My  object 
is  to  show  that  there  is  a  definite  connection  between  sudden 
death  from  inhibition  ;  surgical  shock  as  we  see  it  every  day 
in  hospital ;  post-operative  ileus ;  the  apathetic  death  of  a 
warrior's  lady  "  without  apparent  reason  "  ;  cases  of  delayed 
shock ;  deaths  from  pneumonia  after  some  injuries  ;  and, 
lastly,  traimiatic  neurasthenia. 

The  cHnical  manifestations  of  shock  are,  and  must  be,  as 
various  as  the  diverse  circumstances  that  evoke  it,  and  the 
natures  of  those  in  whom  it  is  evoked.  It  seems  certainly 
as  if  the  visceral  incidence  of  shock  is  sometimes  in  proportion 
to  the  psychical  repression,  and  that  an  adequate  fit  of  hys- 
terics may  be  an  excellent  safeguard  against  traumatic  neuras- 
thenia. But  it  is  a  very  practical  lesson  that,  whether  lawyers 
or  physicians,  we  should  hesitate  to  disregard  "  functional 
symptoms  "  merely  because  our  dull  eyes  can  find  no  organic 
lesion,  which,  if  we  did,  would  probably  be  quite  irrelevant 
except  as  evidence  that  accident  had  occurred. 

It  is  not  an  exaggeration,  though  it  may  seem  a  paradox, 
to  say  that  people  do  not  die  of  organic  disease  so  often  as  of 
disturbances  of  function  ;  although,  after  all,  there  can  hardly 
be  functional  disturbances  without  alteration  in  cellular 
states. 

Something  may  even  be  said  for  the  malingerer.  "  I  do 
not  recollect,"  says  Murri,  "  ever  having  come  to  the  con- 
clusion, in  a  case  of  so-called  '  traumatic  neurosis,'  that  the 
whole  affair  was  a  deception." 

Be  this  as  it  may,  if  we  are  to  recognize,  as  I  think  we  must 
increasingly,  that  even  the  simple  or  apparently  simple  func- 
tional perturbations  of  which  people  complain  or  from  which 
we  see  them  suffer,  after  physical  or  psychical  trauma,  are 
really  consequences  not  within  their  control,  though  pos- 
sibly dependent  on  their  personal  equation,  I  can  foresee  a 
revolution  in  the  attitude  of  insurance  companies  towards 
accident.     I  do  not  think  that  we  doctors  have  any  right, 


SHOCK  45 

except  as  citizens,  to  express  an  opinion  as  to  who  should  or 
who  should  not  be  compensated  by  the  State  or  the  em- 
ployer under  certain  conditions.  We  must  stick  to  our  last, 
and  elucidate  as  honestly  as  we  may  the  chain  of  circumstances 
in  each  case. 

Lawyers  will  doubtless  find  a  congenial  field  in  devising 
formulae  which  will  secure  that  those  receive  compensation 
who  public  opinion  determines  should  be  compensated,  and 
that  others,  who  enter  into  private  contracts  with  insurance 
companies,  be  justly  dealt  with. 

Anyway,  the  responsibihty  for  the  enunciation  of  the  prin- 
ciples of  compensation  does  not,  I  take  it,  rest  with  either 
lawyers  or  physicians  as  such,  though  it  is  our  duty  to  point 
out  where  existing  statutes  or  usual  forms  of  policy  operate 
inequitably,  or  not  as  intended  by  those  who  have  devised 
them. 

When  all  is  said  and  done,  there  is  still  the  element  of 
suggestion,  and  I  do  not  see  why  we  should  hold  anyone 
responsible  for  his  personal  "  suggestibility."  There  is  no 
doubt,  too,  that  the  effects  of  trauma,  physical  and  psychical, 
are  tending  towards  exacerbation  as  a  result  of  the  ever- 
present  suggestion  of  compensation  which  operates,  through 
the  trauma,  on  the  autonomic  system.  And  it  seems  to  me 
that  the  "  suggestibility  "  of  any  person  is  not  easily  to  be 
distinguished  from  what  Mr.  Tyrrell  Gray  calls  his  "  shock 
value." 

The  practical  notion  that  I  put  forward  is  that,  just  as  we 
attempt  to  assay  the  life- value  of  any  candidate  for  life  in- 
surance, so  must  we  address  ourselves  to  estimating  the 
"  shock  value  "  or  suggestibility  of  persons  who  are  to  be 
insured  against  accident. 


LIST  OF  AUTHORS  WHOSE  WORKS  HAVE  BEEN 
CONSULTED  AND  REFERRED  TO. 

Allbutt,  Sir  T.  C.  A.  :  System  of  Medicine,  vol.  iii.,  p.  386  et  seq. 

Armour  :  Clinical  Journal,  March  15,  1905. 

Barry  :  Universal  Medical  Record,  March,  1912,  p.  277. 

Begg  :  Veterinary  Joiornal,  August,  1912. 

BiNNiE  :  Surgery,  GynsecologA^,  and  Obstetrics,  May,  1912. 

Brouardel  and  Benham  :  Death  and  Sudden  Death. 

Brunton,  Sir  Lauder  :  System  of  Medicine,  vol.  iii.     Proceedings  of 

the  Royal  Society  of  Medicine,  April,  1912. 
Cannon  :  Boston  Medical  and  Surgical  Journal,  August  8,  1912. 
Cannon,  Shohland,  and  Wright  :  American  Journal  of  Physiology, 

April  and  December,  1911. 
Cotton:  Boston  Medical  and  Surgical  Journal,  September  26,  1912. 
Crookshank  :  Essays  and  Clinical  Studies,  pp.  288  et  seq. 
Dejerine  :  Universal  Medical  Record,  February,  1912. 
Dent,  T.  Clinton  :  Clinical  Journal,  October  7,  1908. 
Enriques  and  Gaston  Durand  :  La  Presse  Medical,  October  9,  19 12. 
Eusterman  :  Mayo  Clinics,  1910. 

Evans,  H.  Muir  :  British  Medical  Journal,  vol.  i.,  1897, 
Falta  and  Priestley  :  Berlin,  kltn.  Wochenschrift.,  November  20, 

1911. 
Fenwick,  Soltau  :  System  of  Medicine,  vol.  iii. 
Franke  :  Universal  Medical  Record,  October,  1912,  p.  328. 
FucHS  and  Roth  :  Zeits.  fiir  Path.,  vol.  x.,  p.  187,  1912. 
Go\vERS,  Sir  W.  :  Lancet,  1907,  vol.  i.,  p.  1551. 
Gray,  Tyrrell,  and  Leonard  Parsons  :  British  Medical  Journal, 

vol.  i.,  1912. 
Grayson  :  Journal  of  the  American  Medical  Association,  May  25,  1912. 
Held  :  Medical  Record,  August  24,  1912. 
Hemmeter  :  Interstate  Medical  Journal,  March,  1912. 
Henderson,  Yandall  :  American  Journal  of  Physiology,  vols,  xxiv., 

XXV.,   xxvi.,   and  xxvii.     Surgery,   Gynaecology,   and   Obstetrics, 

August,  1911.     (See  also  Worsley,  ibid.,  April,  1912.) 
Herschell  :  Interstate  Medical  Journal,  March,  1912. 
Hoppe-Seyler  :   Vide  Wylie. 

Hoskins  :  Cleveland  Medical  Journal,  March,  1912. 
Hutchison  :  Applied  Physiology,  p.  251. 
Jordan,  Furneaux  :  Surgical  Enquiries. 
Knocker  :  Accidents  in  their  Medico-Legal  Aspect. 
Macdonald  :  Canadian  Medical  Association  Journal,  April,  1912. 
Mackenzie  :  Medical  Chronicle,  1892.     Diseases  of  the  Heart. 
Mayo  :   Vide  Starr. 

Meunier  :  Universal  Medical  Record,  April,  1912,  p.  334. 
MouLLiN,  Mansell  :    Pathology  of  Shock.      Ashurst's  Encyclopaedia 

(art.:  Shock). 

46 


LIST  OF  AUTHORS  47 

Murphy  and  Vincent:  Boston  Medical  and  Surgical  Journal,  1911, 

p  .  684. 
MuRRi :  Universal  Medical  Record,  July  and  August,  1912. 
Neuhof  :  American  Journal  of  the  Medical  Sciences,  May,  1912. 
OsLER,    Sir   W.  :    Principles   and    Practice    of   Medicine.     Universal 

Medical  Record,  Januarj^  1912,  p.  31. 
Page  :  Injuries  of  the  Spine  and  Spinal  Cord.     Railway  Injuries. 
Rankin,  Guthrie  :  British  Medical  Journal,  vol.  ii.,  1911. 
Sajous  :  The  Internal  Secretions,  vol.  i.,  p.  235.     Monthly  CyclopaBdia 

and  Medical  Bulletin,  December,  19 ii. 
Sherrington  :  Encyclopaedia  Britannica,  vol.  xxvi.,  p.  287. 
Starr  :  Canadian  Medical  Association  Journal,  March,  1912. 
Stone,    Bernheim,   and  Whipple  :  Bulletin  of  the   Johns  Hopkins 

Hospital,  June,  191 2. 
Strauss  :  Ibid.,  February  and  April,  19 12. 
Taylor  :  Practice  of  Medicine. 

Thompson,  Campbell  :  Clinical  Journal,  May  22,  1905  ;  June,  1912. 
Trousseau  :  Clinical  Lectures  (New  Sydenham  Society),  vol.  iv. 
Turner  :  Clinical  Journal,  July  24,  1907. 
Verdon  :  Lancet,  June  8,  1912. 

Verworn  :  Bulletin  of  the  Johns  Hopkins  Hospital,  April,  1912. 
Vincent  :  Internal  Secretion  and  the  Ductless  Glands. 
Watson,  Wadsworth  :  Liverpool  Medico-Chirurgical  Journal,  January, 

1912. 
WiLKs,  Sir  S.  :  Lectures  on  Diseases  of  the  Nervous  System. 
Winternitz  :  Bulletin  of  the  Johns  Hopkins  Hospital,  April,  191 1. 
Wyllie  :  Edinburgh  Hospital  Reports,  1895. 
Yeo,  Burney  :  Food  in  Health  and  Disease,  p.  403. 

Some  account  of  the  swimming-bladder  of  fishes  may  be 
found  in  the  "  Encyclopaedia  Britannica  "  (art.  Fishes). 

The  case  of  Etherington  may  be  read  in  any  law  library  by 
reference  to  K.B.,  I.,  591,  1909. 


ERRATA 

Page  37,  footnote,  for  "  Grave's  "  nad  "Graves's." 
Page  46,  Une  16,  for  "  Medical  "  read  "  Medicale." 

line  30, /o»'  "Yandall"  read  "Yandell." 

line  34,  for  "  Wylie  "  read  "  Wyllie." 
Page  47,  line  6  from  end,  for  "  Watson,  Wadsworth  "  read  "  Wads- 
WORTH,  Watson." 


LIST  OF  AUTHORS  WHOSE  WORKS  HAVE  BEEN 
CONSULTED  AND  REFERRED  TO. 

Allbutt,  Sir  T.  C.  A.  :  System  of  Medicine,  vol.  ui.,  p.  386  et  seq. 

Armour  :  Clinical  Journal,  March  15,  1905. 

Barry  :  Universal  Medical  Record,  March,  1912,  p.  277. 

Begg  :  Veterinary  Journal,  August,  1912. 

BiNXiE  :  Surgery,  GjTisecology,  and  Obstetrics,  May,  1912. 

Brouardel  and  Beneam  :  Death  and  Sudden  Death. 

Brunton,  Sir  Lauder  :  System  of  Medicine,  vol.  iii.     Proceedings  of 

the  Royal  Societ^^  of  Medicine,  April,  1912. 
Caxxox  :  Boston  .Medical  and  Surgical  Journal,  August  8,  1912. 
Canxox,  Shohlaxd,  and  Wright  :  American  Journal  of  Physiology, 

April  and  December,  1911. 
Cotton:  Boston  Medical  and  Surgical  Journal,  September  26,  1912. 
Crookshank  :  Essays  and  Clinical  Studies,  pp.  288  et  seq. 
Dejerine  :  Universal  Medical  Record,  February,  1912. 
Dent,  T.  Clinton  :  Clinical  Journal,  October  7,  1908. 
Enriques  and  Gaston  Durand  :  La  Presse  Medical,  October  9,  19 12. 
Eusterman  :  Mayo  Clinics,  1910. 

Evans,  H.  Muir  :'  British  Medical  Journal,  vol.  i.,  1897. 
Falta  and  Priestley  :  Berlin,  klin.  Wochenschrift.,  November  20, 

1911. 
v-c-K-ann-v:   c^nT.TATr  •  SvstftTn  nf  Medicine,  vol.  iiL 


c 


/ 


/ 


LIST  OF  AUTHORS  47 

Murphy  and  Vincent:  Boston  Medical  and  Surgical  Journal,  1911, 

p  .  684. 
MuRRi :  Universal  Medical  Record,  July  and  August,  1912. 
Neuhof  :  American  Journal  of  the  Medical  Sciences,  May,  1912. 
OsLER,    Sir   W.  :    Principles   and    Practice    of   Medicine.     Universal 

Medical  Record,  Januarj^  1912,  p.  31. 
Page  :  Injuries  of  the  Spine  and  Spinal  Cord.     Railway  Injuries. 
Rankin,  Guthrie  :  British  Medical  Journal,  vol.  ii.,  1911. 
Sajous  :  The  Internal  Secretions,  vol.  i.,  p.  235.     Monthly  Cyclopaedia 

and  Medical  Bulletin,  December,  191 1. 
Sherrington  :  Encyclopaedia  Britannica,  vol.  xxvi.,  p.  287. 
Starr  :  Canadian  Medical  Association  Journal,  March,  1912. 
Stone,   Bernheim,   and  Whipple  :  Bulletin  of  the   Johns  Hopkins 

Hospital,  June,  1912. 
Strauss  :  Ibid.,  February  and  April,  1912. 
Taylor  :  Practice  of  Medicine. 

Thompson,  Campbell  :  Clinical  Journal,  May  22,  1905  ;  June,  1912. 
Trousseau  :  Clinical  Lectures  (New  Sydenham  Society),  vol.  iv. 
Turner  :  Clinical  Journal,  July  24,  1907. 
Verdon  :  Lancet,  June  8,  1912. 

Verworn  :  Bulletin  of  the  Johns  Hopkins  Hospital,  April,  1912. 
Vincent  :  Internal  Secretion  and  the  Ductless  Glands. 
Watson,  Wadsworth  :  Liverpool  Medico-Chirurgical  Journal,  January, 

1912. 
WiLKS,  Sir  S.  :  Lectures  on  Diseases  of  the  Nervous  System. 
WiNTERNiTZ  :  Bulletin  of  the  Johns  Hopkins  Hospital,  April,  1911. 
Wyllie  :  Edinburgh  Hospital  Reports,  1895. 
Yeo,  Burney  :  Food  in  Health  and  Disease,  p.  403. 

Some  account  of  the  swimming-bladder  of  fishes  may  be 
found  in  the  "  Encyclopsedia  Britannica  "  (art.  Fishes). 

The  case  of  Etherington  may  be  read  in  any  law  library  by 
reference  to  K.B.,  I.,  591,  1909. 


H.  K.  LEWIS,  136,  GOWER  STREET,  LONDON,  W.C. 


c^^^ 


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